# Prevalence and Determinants of Appropriate Health Seeking Behaviour among Known Diabetics: Results from a Community-Based Survey

Authors: Sheleaswani Inche Zainal Abidin; Rosnah Sutan; Khadijah Shamsuddin
Journal: Advances in Epidemiology
 (2014)

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## Abstract

Introduction. Living with diabetes requires patients to have good self-monitoring of their disease and treatment. Appropriate health seeking behavior is important to minimize complications and improve quality of life. Methodology. A community-based, cross-sectional study of disease events and experiences from diagnosis to the time of study was conducted among 460 known diabetics in Tanjong Karang district. The aim of this study was to describe the current pattern of health seeking behavior and its determinants among rural communities. Appropriate diabetic health services utilization was defined as using modern treatment either through oral hypoglycemics or insulin injections, obtained from either a public or private health facility. Result. 85.9% of respondents reported having appropriate health seeking behaviour at the time of the house-to-house community survey. Multivariate logistic regression analysis revealed that appropriate health seeking behaviour was significantly associated with age of respondent, presence of comorbidity, family history of diabetes, distance from health facilities, perceived family support, and history of early treatment seeking at diagnosis and duration of disease. Conclusion. The present population has better appropriate health seeking behavior and provision of knowledge with strong family support in diabetic care which are important in control and prevention of diabetic complication that need to be emphasized.


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## Body

## 1. Introduction

Diabetes is now regarded as a major public health problem all over the world [1]. The prevalence of diabetes mellitus is reaching epidemic levels worldwide [2, 3]. The World Health Organization (WHO) estimated that the number of people with diabetes mellitus is expected to rise from 171 million in 2000 to 366 million in 2030, as a result of population ageing and urbanization [4]. In Singapore, diabetes mellitus is the 8th leading cause of death with 3% of all deaths being attributable to diabetes alone [5, 6]. In Malaysia, the World Health Organisation has estimated that in 2030, our country would have a total number of 2.48 million people with diabetes compared to 0.94 million in 2000 [7]. Prevalence of people with diabetes aged more than 18 years old increased from 11.6% in 2006 to 15.2% in 2011 [8].Health seeking behaviour are directly related to disease incidence, prevalence and complication. Early recognition of symptom, presentation to healthcare facilities, and compliance with effective treatment can reduce morbidity and thereby mortality [9]. Diabetes is a common disease causing significant morbidity and mortality; thus appropriate health seeking behaviour may help to plan diabetes care and management upon diagnosis so that complication can be minimized and quality of life can be improved. Malaysia is currently experiencing a tremendous increase in prevalence of diabetes mellitus, which presents a great challenge to the Ministry of Health, Malaysia, for designing health care policies and programmes.Health Seeking Behaviour. The definition of health seeking behaviour is often considered vague and difficult to define. There is no common definition agreed upon by sociologists in any sociology literature. Different definition may be used in different studies, despite referring to the same activity. According to sociology literature, health care seeking behaviour will be influenced by the individual self, diseases, and the availability and accessibility of health services. Depending on these determinants and their interactions [10, 11], health care seeking behaviour is a complex outcome of many factors operating at individual, family, and community level. Treatment choices would involve many factors related to illness type and severity, sociodemographic characteristics, preexisting lays believe about illness causation, accessibility of treatment available and their perceived efficacy and disease profile [12].Appropriate health seeking behaviours among people with diabetes in this study are defined as seeking modern/conventional treatment either through oral hypoglycemics or through insulin injections, from public or private health facilities (hospital and clinic) [13]. The use of unconventional treatment is gaining considerable recognition and popularity worldwide. Use of nonmodern/unconventional treatment especially complementary and alternative medicine is common among people with diabetes, and often they may not inform their doctors of their use [12]. It is important to know the usage of unconventional treatment because interaction with conventional treatment may occur. It may even cause severe adverse reaction leading to significant morbidity and mortality [14].Since the 1970s, the Ministry of Health, Malaysia, has taken important steps to develop a good network of health care services in the country. A total of 97% of the citizens have access to health services with the majority having access to a health care system within a 3 km radius from their residence. In East Malaysia, more than 50% of the rural population has access to health services within a 5 km radius from their residence [15]. Despite having good network of health care services, prevalence of seeking care for the illness is still low. Among respondents aged 30 years and above, 92.9 percent among people with diabetes are seeking treatment from health facilities whereas 7.1 percent did not seek any diabetic treatment for their diabetic [16].In Malaysia, information regarding the pattern of behaviour among people with diabetes in seeking health and their utilisation of modern treatment and health facilities is limited. Significant nationwide studies on patterns in utilization of health services and its contributing factors in Malaysia are limited. Research done in 2009 showed that, in health services in Malaysia that are still under utilisation, only 33 percents of respondent had contact with health care professional [17]. Study done by National Health and Morbidity Survey in 2006 also showed similar findings. Only 59.3 percent of respondents are seeking treatment for their illnesses [16]. The objective of this study therefore is to understand current pattern of health seeking behaviour and particularly to determine factors influencing health seeking behaviour known among people with diabetes in Tanjong Karang, Selangor.


## 2. Materials and Methods

### 2.1. Study Design

A cross-sectional study was conducted in selected communities in Tanjong Karang between October 2011 and April 2012. Tanjong Karang was purposely chosen whereby simple random sampling method was used to choose 17 villages. Household survey was done prior to the study to identify people with diabetes. A simple random sampling was used to select respondents who had diabetes from the household survey.


### 2.2. Sample Size

The sample size calculations were done using Power and Sample Size Calculation software. A single proportion formula (Fleiss formula) was used. Calculations were done for all possible variables and the biggest sample size was chosen. The minimum sample size required were 460 (precision level of 0.07, the value of normal standard distribution of 1.96, power of 80%).


### 2.3. Inclusion Criteria

(a)
Villagers from Tanjong Karang who self-reported having diabetes mellitus (types 1 and 2).
(b)
Age ≥ 18 years old.
(c)
Able to read, write, communicate, and understand Bahasa Malaysia.
(d)
Agree to participate


### 2.4. Data Collection

Data were collected by mean of structured face to face interview. People with diabetes were interviewed using a structured validated questionnaire without disturbance in the privacy of their own homes. In order to validate the content of the questionnaires, comments and suggestions from a group of experts including two public health lecturers and one endocrinologist were reviewed. Following the content validity, face validity was carried out. Ten villagers were interviewed with the questionnaires. A few wordings had been changed after the session to improve the contents of the questionnaires. The questionnaire was then piloted among 40 villagers from Kampung Bestari Jaya, Kuala Selangor. It consists of 59 items grouped into 6 domains composed of six parts which were social demographic profile, disease profile, knowledge of diabetes mellitus, perception of diabetes mellitus, family support, and health seeking behaviour. Result of validation shows that the constructed validity and reliability were optimal. Cranach alpha coefficient values for each domain ranged between 0.6 and 0.9.The following operational definitions were used.Health seeking behaviour was defined as follows: respondent who reported visiting any health facilities (government or private) and using modern treatment (oral hypoglycaemic agent or insulin therapy). Appropriate health seeking behaviours are defined as respondents seeking modern treatment either through oral hypoglycemics or through insulin injections, from a public or private clinic or hospital [13].


### 2.5. Ethical Approval

This study was reviewed and approved by the Research and Ethics Committee, National University of Malaysia, Grant no. FF-045-2011.


### 2.6. Data Analysis

Data entry and statistical analysis were done using SPSS version 20. The continuous variables were recorded as mean and standard deviation (SD). Categorical variables were recorded as frequencies and percentages. Simple logistic regression was used as a screening in selection of variables for further analysis. All variables withP value less than 0.20 and clinically relevant variables were included in the multiple logistic regression analysis. The method that was used for variable selection was enter, backward, and forward stepwise procedure. All possible 2-way interactions were checked and those significant variables were included in the model. The independent variables were fitted into multiple logistic regression and multicollinearity was checked. Fitness of model was tested by Hosmer-Lemeshow goodness of fit test, the classification table, and receiver operator characteristic curve. P<0.05 was set as significant level.


## 2.1. Study Design

A cross-sectional study was conducted in selected communities in Tanjong Karang between October 2011 and April 2012. Tanjong Karang was purposely chosen whereby simple random sampling method was used to choose 17 villages. Household survey was done prior to the study to identify people with diabetes. A simple random sampling was used to select respondents who had diabetes from the household survey.


## 2.2. Sample Size

The sample size calculations were done using Power and Sample Size Calculation software. A single proportion formula (Fleiss formula) was used. Calculations were done for all possible variables and the biggest sample size was chosen. The minimum sample size required were 460 (precision level of 0.07, the value of normal standard distribution of 1.96, power of 80%).


## 2.3. Inclusion Criteria

(a)
Villagers from Tanjong Karang who self-reported having diabetes mellitus (types 1 and 2).
(b)
Age ≥ 18 years old.
(c)
Able to read, write, communicate, and understand Bahasa Malaysia.
(d)
Agree to participate


## 2.4. Data Collection

Data were collected by mean of structured face to face interview. People with diabetes were interviewed using a structured validated questionnaire without disturbance in the privacy of their own homes. In order to validate the content of the questionnaires, comments and suggestions from a group of experts including two public health lecturers and one endocrinologist were reviewed. Following the content validity, face validity was carried out. Ten villagers were interviewed with the questionnaires. A few wordings had been changed after the session to improve the contents of the questionnaires. The questionnaire was then piloted among 40 villagers from Kampung Bestari Jaya, Kuala Selangor. It consists of 59 items grouped into 6 domains composed of six parts which were social demographic profile, disease profile, knowledge of diabetes mellitus, perception of diabetes mellitus, family support, and health seeking behaviour. Result of validation shows that the constructed validity and reliability were optimal. Cranach alpha coefficient values for each domain ranged between 0.6 and 0.9.The following operational definitions were used.Health seeking behaviour was defined as follows: respondent who reported visiting any health facilities (government or private) and using modern treatment (oral hypoglycaemic agent or insulin therapy). Appropriate health seeking behaviours are defined as respondents seeking modern treatment either through oral hypoglycemics or through insulin injections, from a public or private clinic or hospital [13].


## 2.5. Ethical Approval

This study was reviewed and approved by the Research and Ethics Committee, National University of Malaysia, Grant no. FF-045-2011.


## 2.6. Data Analysis

Data entry and statistical analysis were done using SPSS version 20. The continuous variables were recorded as mean and standard deviation (SD). Categorical variables were recorded as frequencies and percentages. Simple logistic regression was used as a screening in selection of variables for further analysis. All variables withP value less than 0.20 and clinically relevant variables were included in the multiple logistic regression analysis. The method that was used for variable selection was enter, backward, and forward stepwise procedure. All possible 2-way interactions were checked and those significant variables were included in the model. The independent variables were fitted into multiple logistic regression and multicollinearity was checked. Fitness of model was tested by Hosmer-Lemeshow goodness of fit test, the classification table, and receiver operator characteristic curve. P<0.05 was set as significant level.


## 3. Results

Out of the 506 respondents visited in the survey, there were a total of 460 respondents, giving a response rate of 90.9%.


### 3.1. Sociodemographic and Disease Profile of Respondents

A total of 460 villagers were interviewed. The mean age of the respondents was 53.5 ± 13 years, with slightly more females (62.6%). The mean households’ size was 4. The median monthly households’ income was RM 1000. The majority (84.3%) of villagers had formal education up to secondary level. Majority of respondents were Malays (93.5%), Islam (93.5%), married (79.1%), working (32.4%) and housewife (32.8%) (Table1).Table 1
Sociodemographics and disease profile of the respondents (N=460).
Characteristics
n
=
460
(%)
Gender
Male
172
37.4
Female
288
62.6
Ethnic
Malay
430
93.5
Chinese
21
4.6
Indian
9
1.9
Religion
Islamic
430
93.5
Hindu
21
4.6
Buddha
9
1.9
Occupation
Working
149
32.4
Unemployed
85
18.5
Housewife
151
32.8
Pensioners
70
15.2
Students
5
1.1
Education
No education
73
15.9
Primary school
155
33.7
Secondary school
182
39.6
University/college
50
10.9
Marital status
Bachelor
13
2.8
Married
364
79.1
Widowed
23
5.1
Divorced
60
13.1
Duration of illness
Mean ± (sd) 7.28 (5.65)
Less than 5 years
220
47.8
5–10 years
120
26.0
11–19 years
98
21.4
>20 years
22
4.8
Comorbidity
Yes
283
61.5
No
177
38.5
Complication of diabetes mellitus
Yes
198
43.0
No
262
57.0
Family history of diabetes mellitus
Yes
250
54.3
No
210
45.7The majority of respondents reported having diabetes mellitus less than 5 years (47.8%). Most of the respondents were having comorbidity (61.5%) and close family members diagnosed with diabetes mellitus (54.3%). 27% of respondents reported their diabetes being diagnosed by opportunistic medical screening at health facilities and only 26.5% by their own initiatives going to health facilities for medical screening.Table2 shows the current pattern of health seeking behaviour. Appropriate health seeking behaviour were classified as respondents seeking treatment within 24 hours upon diagnosis, utilizing health facilities and using modern treatment. Reason for not seeking medical treatment included, able to treat themselves, no time and financial constraints.Table 2
Current pattern of health seeking behavior.
Characteristics
n
%
Method of DM being diagnosed
Medical screening at community level
30
6.5
Medical screening at health facilities
124
27.0
Own initiatives
122
26.5
Medical checkup (preemployment/hajj)
36
7.8
Getting treatment for symptom of DM
69
15.0
Admitted to hospital due to complication of DM
47
10.2
Medical screening 6 weeks postpartum.
32
7.0
Seeking treatment upon diagnosis
Yes
376
81.7
No
84
18.3
Early treatment at diagnosis
Within 24 hours
222
48.3
After 24 hours
154
33.4
Reason for not/delay in  seeking treatment upon diagnosis
Financial constraint (transport, medicine, and consultation)
46
10.0
No time
114
24.8
Distance from health facilities
26
5.7
Considered that symptoms were not serious enough for treatment
27
5.9
Self-treatment
206
44.8
No treatment
5
1.1
>2 reasons
36
7.8
Utilizing health facilities
Government hospital
263
57.2
Private hospital
23
5.0
Government clinic
114
24.8
Private clinic
13
2.8
Pharmacy/Chinese shop
7
1.5
Traditional healers
—
—
Homeopathy healers
2
0.4
Self-treatment
30
6.5
No treatment
8
1.7
Using modern treatment
Oral diabetic agent
308
67.0
Insulin
43
9.3
Oral diabetic agent and insulin
53
11.5
Traditional medicine
4
0.9
Homeopathy medicine
3
0.7
Food supplement
7
1.5
Medicine bought from pharmacy
3
0.7
Medicine bought from Chinese shop
6
1.3
Self-treatment
23
5.0
No treatment
10
2.2
Health seeking behaviour
Appropriate
395
85.9
Inappropriate
65
14.1Table3 showed that age of respondent, marital status, educational attainment, employment status, household income, household size, distance from health facilities, transportation, duration of illness, present of co-morbidity, family history of Diabetes mellitus, duration of seeking treatment upon diagnosis, level of family support and perception of diabetes mellitus were associated with health seeking behaviour.Table 3
Factors associated with appropriate health seeking behaviour.
Variables
Health seeking behaviour
χ
P value
Appropriate (n/%)
Inappropriate (n/%)
Age  (years)
<35
364 (88.3)
48 (11.8)
18.725
<0.001
≥35
31 (64.6)
17 (35.4)
Sex
Male
147 (85.5)
25 (14.5)
0.283
0.595
Female
248 (86.1)
40 (13.9)
Marital status
Married
307 (84.3)
305 (83.8)
3.786
0.052
Not married  (bachelor, widow)
88 (11.7)
88 (91.7)
Educational level
High
190 (81.9)
42 (18.1)
5.926
0.015
Low
205 (89.9)
23 (10.1)
Employment status
Working
117 (78.5)
32 (21.5)
10.182
0.001
Not working
278 (89.4)
33 (10.6)
Mean household income  (RM)
<770
152 (91.0)
15 (9.0)
6.568
0.010
≥770
243 (82.9)
50 (17.1)
Household size  (person)
≥5
138 (83.1)
28 (16.9)
1.761
0.185
<5
257 (87.4)
37 (12.6)
Distance from health facilities  (kilometre)
1.165
0.280
≥5
206 (88.0)
28 (16.0)
<5
189 (83.6)
37 (16.4)
Having transportation
Yes
376 (85.5)
64 (14.5)
1.537
0.215
No
19 (95.0)
1 (5.0)
Duration of illness  (years)
>5
187 (78.6)
51 (21.4)
21.024
<0.001
≤5
208 (93.7)
14 (6.3)
Comorbidity
Yes
131 (74.9)
44 (25.1)
31.181
<0.001
No
264 (92.6)
21 (7.4)
Family history of  diabetes mellitus
Yes
165 (78.6)
45 (21.4)
18.968
<0.001
No
230 (92.0)
20 (8.0)
Complication of diabetes mellitus
Yes
169 (85.4)
29 (14.6)
0.331
0.595
No
226 (86.3)
36 (13.7)
Early treatment at diagnosis
Yes
199 (89.6)
23 (10.4)
15.120
<0.001
No
196 (82.4)
42 (17.6)
Family support
High
223 (88.1)
30 (11.9)
2.416
0.120
low
172 (83.1)
35 (16.9)
Knowledge of diabetes mellitus
Good
226 (85.9)
37 (14.1)
0.122
0.727
Poor
169 (85.8)
28 (14.2)
Perception of respondent toward risk of getting diabetes
Positive
152 (84.9)
27 (15.1)
0.219
0.639
Negative
243 (86.5)
38 (15.5)
Perception of respondent towards personal control
Positive
133 (82.1)
29 (17.9)
2.930
0.087
Negative
262 (87.9)
36 (12.1)
Perception of respondent towards benefit and barriers of preventive behaviour
Positive
81 (87.1)
12 (12.9)
0.145
0.749
Negative
314 (85.6)
53 (14.4)
Method of DM being diagnosed
Medical screening at community level
26 (86.7)
4 (13.3)
16.120
0.013
Medical screening at health facilities
115 (92.7)
9 (7.3)
Own initiatives
103 (84.4)
19 (15.6)
Medical checkup  (preemployment/haji)
27 (75.0)
9 (25.0)
Getting treatment for symptom of DM
62 (89.9)
7 (10.1)
Admitted to hospital due to complication of DM
39 (83.0)
8 (17.0)
Medical screening 6 weeks postpartum
23 (71.9)
9 (28.1)Table4 presented the adjusted odds ratio for likelihood of appropriate health seeking behaviour. When all predictive variables from the Bivariate analysis were entered in the multivariate analysis, absence of comorbidity (OR 3.15, 95% CI 1.66–5.98), seeking treatment within 24 hours of diagnosis (OR 2.62, 95% CI 1.35–5.07), duration of illness less than 5 years (OR 3.40, 95%CI 1.69–6.08) and those having high family support (OR 2.56, 95%CI 1.25–7.69) were determinants for appropriate health seeking behaviour.Table 4
Logistic regression predicting likelihood of appropriate health seeking behavior.
Characteristic
β
SE
WALD
P value
Expβ
95% CI
Constant
2.394
0.346
47.822
<0.001
10.953
Age (years)
≥35 <35
0.956
0.420
5.174
0.023
1.002.60
1.14–5.92
Comorbidity
Yes No
1.212
0.318
14.527
<0.001
1.003.15
1.66–5.98
Family history of diabetes mellitus
Yes No
1.147
0.328
12.281
<0.001
1.003.36
1.80–6.27
Distance from health facilities (kilometre)
<5 ≥5
0.699
0.312
5.035
0.025
1.002.01
1.08–3.70
Seeking treatment upon diagnosis (within 24 hours)
Yes No
0.962
0.337
8.156
0.004
2.621.00
1.35–5.07
Duration of illness (years)
>5 ≤5
1.222
0.355
11.860
0.001
1.003.40
1.69–6.08
Complication of diabetes mellitus
Yes No
−0.584
0.318
3.369
0.066
1.000.588
0.30–1.04
Family support
low high
−1.112
0.456
5.949
0.015
1.002.56
1.25–7.69
R
2 = 0.789 (Hosmer and Lemeshow), 0.25 (Cox and Snell), and 0.38 (Nagelkerke). Model χ2(28) = 136, P<0.001.


## 3.1. Sociodemographic and Disease Profile of Respondents

A total of 460 villagers were interviewed. The mean age of the respondents was 53.5 ± 13 years, with slightly more females (62.6%). The mean households’ size was 4. The median monthly households’ income was RM 1000. The majority (84.3%) of villagers had formal education up to secondary level. Majority of respondents were Malays (93.5%), Islam (93.5%), married (79.1%), working (32.4%) and housewife (32.8%) (Table1).Table 1
Sociodemographics and disease profile of the respondents (N=460).
Characteristics
n
=
460
(%)
Gender
Male
172
37.4
Female
288
62.6
Ethnic
Malay
430
93.5
Chinese
21
4.6
Indian
9
1.9
Religion
Islamic
430
93.5
Hindu
21
4.6
Buddha
9
1.9
Occupation
Working
149
32.4
Unemployed
85
18.5
Housewife
151
32.8
Pensioners
70
15.2
Students
5
1.1
Education
No education
73
15.9
Primary school
155
33.7
Secondary school
182
39.6
University/college
50
10.9
Marital status
Bachelor
13
2.8
Married
364
79.1
Widowed
23
5.1
Divorced
60
13.1
Duration of illness
Mean ± (sd) 7.28 (5.65)
Less than 5 years
220
47.8
5–10 years
120
26.0
11–19 years
98
21.4
>20 years
22
4.8
Comorbidity
Yes
283
61.5
No
177
38.5
Complication of diabetes mellitus
Yes
198
43.0
No
262
57.0
Family history of diabetes mellitus
Yes
250
54.3
No
210
45.7The majority of respondents reported having diabetes mellitus less than 5 years (47.8%). Most of the respondents were having comorbidity (61.5%) and close family members diagnosed with diabetes mellitus (54.3%). 27% of respondents reported their diabetes being diagnosed by opportunistic medical screening at health facilities and only 26.5% by their own initiatives going to health facilities for medical screening.Table2 shows the current pattern of health seeking behaviour. Appropriate health seeking behaviour were classified as respondents seeking treatment within 24 hours upon diagnosis, utilizing health facilities and using modern treatment. Reason for not seeking medical treatment included, able to treat themselves, no time and financial constraints.Table 2
Current pattern of health seeking behavior.
Characteristics
n
%
Method of DM being diagnosed
Medical screening at community level
30
6.5
Medical screening at health facilities
124
27.0
Own initiatives
122
26.5
Medical checkup (preemployment/hajj)
36
7.8
Getting treatment for symptom of DM
69
15.0
Admitted to hospital due to complication of DM
47
10.2
Medical screening 6 weeks postpartum.
32
7.0
Seeking treatment upon diagnosis
Yes
376
81.7
No
84
18.3
Early treatment at diagnosis
Within 24 hours
222
48.3
After 24 hours
154
33.4
Reason for not/delay in  seeking treatment upon diagnosis
Financial constraint (transport, medicine, and consultation)
46
10.0
No time
114
24.8
Distance from health facilities
26
5.7
Considered that symptoms were not serious enough for treatment
27
5.9
Self-treatment
206
44.8
No treatment
5
1.1
>2 reasons
36
7.8
Utilizing health facilities
Government hospital
263
57.2
Private hospital
23
5.0
Government clinic
114
24.8
Private clinic
13
2.8
Pharmacy/Chinese shop
7
1.5
Traditional healers
—
—
Homeopathy healers
2
0.4
Self-treatment
30
6.5
No treatment
8
1.7
Using modern treatment
Oral diabetic agent
308
67.0
Insulin
43
9.3
Oral diabetic agent and insulin
53
11.5
Traditional medicine
4
0.9
Homeopathy medicine
3
0.7
Food supplement
7
1.5
Medicine bought from pharmacy
3
0.7
Medicine bought from Chinese shop
6
1.3
Self-treatment
23
5.0
No treatment
10
2.2
Health seeking behaviour
Appropriate
395
85.9
Inappropriate
65
14.1Table3 showed that age of respondent, marital status, educational attainment, employment status, household income, household size, distance from health facilities, transportation, duration of illness, present of co-morbidity, family history of Diabetes mellitus, duration of seeking treatment upon diagnosis, level of family support and perception of diabetes mellitus were associated with health seeking behaviour.Table 3
Factors associated with appropriate health seeking behaviour.
Variables
Health seeking behaviour
χ
P value
Appropriate (n/%)
Inappropriate (n/%)
Age  (years)
<35
364 (88.3)
48 (11.8)
18.725
<0.001
≥35
31 (64.6)
17 (35.4)
Sex
Male
147 (85.5)
25 (14.5)
0.283
0.595
Female
248 (86.1)
40 (13.9)
Marital status
Married
307 (84.3)
305 (83.8)
3.786
0.052
Not married  (bachelor, widow)
88 (11.7)
88 (91.7)
Educational level
High
190 (81.9)
42 (18.1)
5.926
0.015
Low
205 (89.9)
23 (10.1)
Employment status
Working
117 (78.5)
32 (21.5)
10.182
0.001
Not working
278 (89.4)
33 (10.6)
Mean household income  (RM)
<770
152 (91.0)
15 (9.0)
6.568
0.010
≥770
243 (82.9)
50 (17.1)
Household size  (person)
≥5
138 (83.1)
28 (16.9)
1.761
0.185
<5
257 (87.4)
37 (12.6)
Distance from health facilities  (kilometre)
1.165
0.280
≥5
206 (88.0)
28 (16.0)
<5
189 (83.6)
37 (16.4)
Having transportation
Yes
376 (85.5)
64 (14.5)
1.537
0.215
No
19 (95.0)
1 (5.0)
Duration of illness  (years)
>5
187 (78.6)
51 (21.4)
21.024
<0.001
≤5
208 (93.7)
14 (6.3)
Comorbidity
Yes
131 (74.9)
44 (25.1)
31.181
<0.001
No
264 (92.6)
21 (7.4)
Family history of  diabetes mellitus
Yes
165 (78.6)
45 (21.4)
18.968
<0.001
No
230 (92.0)
20 (8.0)
Complication of diabetes mellitus
Yes
169 (85.4)
29 (14.6)
0.331
0.595
No
226 (86.3)
36 (13.7)
Early treatment at diagnosis
Yes
199 (89.6)
23 (10.4)
15.120
<0.001
No
196 (82.4)
42 (17.6)
Family support
High
223 (88.1)
30 (11.9)
2.416
0.120
low
172 (83.1)
35 (16.9)
Knowledge of diabetes mellitus
Good
226 (85.9)
37 (14.1)
0.122
0.727
Poor
169 (85.8)
28 (14.2)
Perception of respondent toward risk of getting diabetes
Positive
152 (84.9)
27 (15.1)
0.219
0.639
Negative
243 (86.5)
38 (15.5)
Perception of respondent towards personal control
Positive
133 (82.1)
29 (17.9)
2.930
0.087
Negative
262 (87.9)
36 (12.1)
Perception of respondent towards benefit and barriers of preventive behaviour
Positive
81 (87.1)
12 (12.9)
0.145
0.749
Negative
314 (85.6)
53 (14.4)
Method of DM being diagnosed
Medical screening at community level
26 (86.7)
4 (13.3)
16.120
0.013
Medical screening at health facilities
115 (92.7)
9 (7.3)
Own initiatives
103 (84.4)
19 (15.6)
Medical checkup  (preemployment/haji)
27 (75.0)
9 (25.0)
Getting treatment for symptom of DM
62 (89.9)
7 (10.1)
Admitted to hospital due to complication of DM
39 (83.0)
8 (17.0)
Medical screening 6 weeks postpartum
23 (71.9)
9 (28.1)Table4 presented the adjusted odds ratio for likelihood of appropriate health seeking behaviour. When all predictive variables from the Bivariate analysis were entered in the multivariate analysis, absence of comorbidity (OR 3.15, 95% CI 1.66–5.98), seeking treatment within 24 hours of diagnosis (OR 2.62, 95% CI 1.35–5.07), duration of illness less than 5 years (OR 3.40, 95%CI 1.69–6.08) and those having high family support (OR 2.56, 95%CI 1.25–7.69) were determinants for appropriate health seeking behaviour.Table 4
Logistic regression predicting likelihood of appropriate health seeking behavior.
Characteristic
β
SE
WALD
P value
Expβ
95% CI
Constant
2.394
0.346
47.822
<0.001
10.953
Age (years)
≥35 <35
0.956
0.420
5.174
0.023
1.002.60
1.14–5.92
Comorbidity
Yes No
1.212
0.318
14.527
<0.001
1.003.15
1.66–5.98
Family history of diabetes mellitus
Yes No
1.147
0.328
12.281
<0.001
1.003.36
1.80–6.27
Distance from health facilities (kilometre)
<5 ≥5
0.699
0.312
5.035
0.025
1.002.01
1.08–3.70
Seeking treatment upon diagnosis (within 24 hours)
Yes No
0.962
0.337
8.156
0.004
2.621.00
1.35–5.07
Duration of illness (years)
>5 ≤5
1.222
0.355
11.860
0.001
1.003.40
1.69–6.08
Complication of diabetes mellitus
Yes No
−0.584
0.318
3.369
0.066
1.000.588
0.30–1.04
Family support
low high
−1.112
0.456
5.949
0.015
1.002.56
1.25–7.69
R
2 = 0.789 (Hosmer and Lemeshow), 0.25 (Cox and Snell), and 0.38 (Nagelkerke). Model χ2(28) = 136, P<0.001.


## 4. Discussion

The prevalence of appropriate health seeking behaviour among people with diabetes in Tanjong Karang, Selangor, was 14.6%. There is no reported study on the prevalence of appropriate health seeking behaviour among people with diabetes in Malaysia. However, the findings are comparable with few studies done in developed and developing countries [18, 19]. A study done by Khongbuh et al., 2005 showed 63.4 % from 495 respondent sought treatment for their diabetics from different type of practitioner [18]. A qualitative study done by Hjelm and Atwine in Uganda also showed that healthcare were mainly sought among doctor and nurses in the professional sector [19].This study also showed that utilizing the health facilities (89.8%) and using modern medicine (87.8%) for treatment of people with diabetes in Tanjong Karang are still low. This finding is discordant with a previous national study in 2011 where utilizing health facilities (96.9%) and using modern medicine (94.2%) are high [3]. The different observe here most probably due to the differences in methodologies (different approach in data collection, study population, location of studies, and difference in definition of health seeking behaviour).Previous studies had proved that certain patient and disease factors can predict appropriate health seeking behavior [20, 21]. Gender, age, racial group, income, educational level, and presence of chronic disorder are some predictive factors. The present study has demonstrated that age of respondents, educational level, employment status, mean household income, duration of illness, presence of other illnesses, close family having history of diabetes mellitus, duration of seeking treatment upon diagnosis, family support, and perception severity of disease were determinants of appropriate health seeking behaviour. However, on multivariate analysis, presence of other illnesses, having close family members diagnosed with diabetes mellitus, duration of illness more than 5 years, duration of seeking treatment within 24 hours of diagnosis, and high family support remained as determinants of appropriate health seeking behavior. These findings are comparable with other studies done in the Western population [20] and Asian population [21].There is a need to have an information regarding health seeking behaviour among people with diabetes particularly related to utilization of health facilities and consuming modern medicine. The information is crucial in order to develop strategies for prevention of complication and adaptation to the treatment. The association of appropriate health seeking behaviour with family members having diabetes mellitus and family support found in this study highlight the potential importance of family empowerment in promoting appropriate health seeking behaviour among people with diabetes.


## 5. Conclusion

This study revealed that prevalence of seeking appropriate health treatment among people with diabetes in Tanjong Karang, Selangor, is still low. Presence of other illnesses, having close family members diagnosed with diabetes mellitus, duration of illness more than 5 years, duration of seeking treatment within 24 hours of diagnosis, and high family support are determinants of appropriate health seeking behaviour.



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*Source: 793286-2014-11-11.xml*