By Paul Andrew Bourne
INTRODUCTION
Health is the bedrock upon which all human societies exist. Thus, the health status of a populace plays an imperative role in the wellbeing of people within a topology and social space. Many people throughout the world and in particular Jamaica conceptualize health and health care as the absence of physical pain and as such, those indicators primarily constitute health from a one-dimensional positivistic space. This is based on the biomedical conceptualization of the phenomenon. Human existence is continuously interfacing social, cultural, psychological, and political experiences and so the biomedical theorizing is a simplistic perspective on the subject matter as health is the absence of illness and the psychosocial well-being of an individual. People casually perceive health or primarily from the perspective of physical illnesses much so that in the absence of certain physiological indicator they perceive of themselves to be healthy, and so they will address matters relating to its care based on their socio-cultural attitude and valuation. Health, despite its fundamentality to existence, is not limited to a single space (i.e. quantification) as human beings are physiological, social, psychological and highly subjective. Thus, health care-seeking behaviour should not be constricted to mere absence of physical illnesses because this is quantifiable but the phenomenon must be analyzed from within a psychosocial space in addition to the traditionalist theorizing.
The dominance of positivistic science in measuring health speaks to a number of the psychosocial ills that are unaddressed to by countless Jamaicans, and this will continue in the distant future if the traditional viewpoint of health is not abated with proper education. Furthermore, if the level of education of a group of people is relatively low or even mediocre, what are the possible outcomes of their perspective on many issues including that of health care?
Health and its care are not only indicators of well-being but health status is also a determinant of human development, and so must become a concern for policy-makers. Thus, the one-dimensional perspective of health and health care permeates the human space and explains the high preponderance of research on this conceptual definition. This explains why there are no statistical agencies in Jamaica that are collecting data on issues such as frequency of visits to gymnasiums, knowledge and healthy eating and ‘best practice’ in regards to preventative care. It is because of the importance of this phenomenon that has fostered the author’s investigation of the matter. In order to present a perspective of Jamaicans on health care, the author will use a secondary data source. The purpose of this approach is to establish external validity, and to formulate a framework on the health seeking behaviours of Jamaicans. This paper is structured in three categories. Firstly, in order that the reader will thoroughly grasp the data analyzed that will come in the latter section of the work, the author thought it fitting to present the methods that were used in the interpretation and assessment of the data. Secondly, a theoretical framework coupled with a literature review of past materials on the area is presented to guide the concept of health care seeking behaviour for the readers. Finally, the data and their interpretations are presented with summary of the entire paper.
It is extremely difficult to define health in an operational term that simple, as the concept is multi-dimensional, in part, and must include a social realm. Hence, health will be conceptualized within the operationalization of the WHO’s Constitution of 1946: “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity (Quoted in Lamb and Siegel, 2004, p.342). This, therefore, comprise biomedical conditions, lifestyle habits, access to care and quality of life conditions. Abramson and Abramson’s (1999) view on the subject aptly describes the matter, that health is to be judged from the aspects of how well people perform everyday activities, to what extent he/she is capable of taking part in social activities, and the harmonious relationship that he/she has with the environment.
This study seeks to explore the determinants of health care seeking behaviour. Jamaica’s population continues to increase while the youth male adults are experience-increasing injuries in addition there are concerns for care for the elderly. Injuries, for example, are among the leading causes of discharge from government hospital, and thus demand the continuous use of such facilities. This diagnosis is very costly to the government of Jamaica in order to effectively plan for health care for the populace. Therefore, the researchers strongly believe that this would be of paramount importance to health analysts, health practitioners and planners. Within the construct of the socio-demographic realities of this society, this research seeks to postulate a causal relationship between the health care seeking behaviour and other factors.
Rationale
Health care seeking behaviour in Jamaica is an important policy issue. It is encouraged, especially in light of preventative care that is cheaper than curative care as well as less costly on the government’s health budget. This paper seeks to explain the variation in health seeking behaviour of Jamaicans who are between 15 and 99 years old when combined for levels of education, poverty (using quintiles), union status, gender, per capita consumption, health insurance, injuries, illness and age of respondents.
Theoretical Framework
Pender, Murdaugh, & Parsons (2002) cited social psychological theory, developed by Lewin. He conceptualized the life space in which an individual exists as composed of regions, some having negative valence, some having positive valence, and others being neutral. Illnesses are conceived to be regions of negative valence applying a force moving the person away from the region. Health-protecting behaviours are strategies for avoiding the negatively valenced regions of illness.
A group of writers who carried out an analysis of a secondary data set (1995 Guatemalan Survey of Family Health (EGSF)) on ‘health seeking behaviour for children with illness in Guatemala’ discovered that a causal relationship exists between a number of illnesses and health seeking behaviour (Noreen Goldman1 and Patrick Heuveline, 2000). Many studies have shown that illnesses determine the degree of health-care seeking behaviour of people. The typologies and severity of diseases are primarily factors that deal to health-seeking behaviour. Studies have shown that men are less likely to seeking health care compared with females because of socialization and it interpretation of ‘machoism’ but in the even that the illness is chronic (i.e. heart disease, stroke, cancer), there is no distinction between the sexes in regard to the desire for health-care seeking behaviour.
Pender, Murdaugh, & Parsons (2002) cited Ajzen and Fishbein proposed Theory of Reasoned Action (TRA) in which attitudes and subjective norms, both constitute the building blocks of this theory. The determinant of intention, attitude toward behaviour, is a function of beliefs concerning the consequences of performing the behaviour and evaluation of each of these consequences as either positive or negative. Evaluation of outcomes of behaviour desirable results is a positive attitude, and if undesirable, it is negative. Another determinant of intention, subjective norms is a function of what significant others expect a person to do; that is, what they would approve or disapprove. The TRA assumes that behaviour is under volitional control.
With reference to “Theory of Planned Behaviour/ Reasoned Action” the Theory of Reasoned Action suggests that a person's behaviour is determined by his/her intention to perform the behaviour and that this intention is, in turn, a function of his/her attitude toward the behaviour and his/her subjective norm. (Smith, R., and Biddle, J. 1999; Eysenck, M., 2004; Harry, P. et al., 2005) The best predictor of behaviour is intention. Intention is the cognitive representation of a person's readiness to perform a given behaviour, and it is considered the immediate antecedent of behaviour. Three things determine this intention: their attitude toward the specific behaviour, their subjective norms and their perceived behavioural control. The theory of planned behaviour holds that only specific attitudes toward the behaviour in question can be expected to predict that behaviour. In addition to measuring attitudes toward the behaviour, we also need to measure people’s subjective norms – their beliefs about how people they care about will view the behaviour in question. To predict someone’s intentions, knowing these beliefs can be as important as knowing the person’s attitudes. Finally, perceived behavioural control influences intentions. Perceived behavioural control refers to people's perceptions of their ability to perform a given behaviour. These predictors lead to intention. A general rule, the more favorable the attitude and the subjective norm, and the greater the perceived control the stronger should the person’s intention to perform the behaviour in question.
The Social Cognitive Theory (SCT) is relevant to health communication. First, the theory deals with cognitive, emotional aspects and aspects of behaviour for understanding behavioural change. (Bandera, 2004; Easton, M. and LaRose, R., 2005) Second, the concepts of the SCT provide ways for new behavioural research in health education. Finally, ideas for other theoretical areas such as psychology are welcomed to provide new insights and understanding.
Many writers who have written on “Social Cognitive Theory”, views human behaviour as a triadic, dynamic, and reciprocal interaction of personal factors, behaviour, and the environment (Martin, J. and Kulinna, P., 2005). Based on this theory, each of these three factors uniquely determines an individual’s behaviour. While the SCT upholds the behaviourist notion that response consequences mediate behaviour, it contends that behaviour is largely regulated antecedently through cognitive processes (Rogers, L et al., 2005). Therefore, response consequences of a behaviour are used to form expectations of behavioural outcomes. It is the ability to form these expectations that give humans the capability to predict the outcomes of future behaviour. In addition, the SCT posits that most behaviour is learned vicariously.
The SCT’s strong emphasis on one's cognitions suggests that the mind is an active force that constructs one's reality, selectively encodes information, performs behaviour based on values and expectations, and imposes structure on its own actions. Through feedback, a person's own reality is formed by the interaction of the environment and one's cognitions. Cognitions change over time because of maturation and experience. It is through an understanding of the processes involved in one's construction of reality that enables human behaviour to be understood, predicted, and changed.
With reference to “Expectancy-Value Theory”, behaviour is a function of the expectancies one has and the value of the goal toward which one is working. Such an approach predicts that, when more behaviours are possible, the behaviour chosen will be the one with the largest combination of expected success and value. Expectancy-value theories hold that people are goal-oriented beings. The behaviours they perform in response to their beliefs and values are undertaken to achieve some end. Other factors influence the process. For example the social and psychological origins of needs, which give rise to motives for behaviour, which may be guided by beliefs, values, and social circumstances into seeking various gratifications.
LITERATURE REVIEW
International perspectives
One writer forward the perspective that “studies that have examined the health-seeking behaviour of elderly people in developing countries reveal several important determinants: age, sex and poverty (18); expectations about aging (19); interpretation and experience of symptoms (20); and the degree of social integration into community (21) among other” (Ahmed, et al., 2005). Although this research is not fashioned with the ambits of the former, the determinants were factors in determining health-care seeking behaviour of particular age cohorts; and so this research will apply those same variables but for individuals between 15 and 99 years old.
According to the writers Kazanjian, Morettin and Cho (2004) who did a study on the utilization of health care by Canadian women, women are twice as likely as men to report a regular family physician, but that proportion could be regarded as insignificant. In Canada, researchers stated that women are more regular users of health services than men are. Sex differences in health services utilization is disease specific, reflecting the biomedical approach to exploring health and illness. The researchers identified data from Statistics Canada which show that while 81.3% of the population, 12 years and older, had contact with medical doctors in the preceding 12 months, 87.2% of the female population reported such contact in the same period. On the other hand, women and girls were less likely to have had no contact with medical providers than men and boys.
There is a significant probability for women than men to present themselves for medical care or consultation. Women are dependent on the health care system to guarantee, control or terminate their fertility. Healthy women are expected to have their regular female related check ups, as a result they could be regarded as over users of the system relative to men.
The writers Kazanjian, Morettin and Cho (2004) postulated that there is a greater expectation for women than men to present themselves for medical care or consultation. Although women’s passage through the life cycle is both social and biological processes, in medical terms the focus is on the biological process. Medical management of men occurs only in the military and sometimes at the beginning of employment.
Cost is yet another factor discouraging utilization of mental health services. Minorities are less likely than Caucasian to have private health insurance, but this factor alone may have little bearing on access to such schemes. Public sources of insurance and publicly supported treatment programs fill some of the gap. Even among working class and middle-class African Americans who have private health insurance, there is under representation of African Americans in outpatient treatment. Yet studies focusing only on poor women, most of whom were members of minority groups, have found cost and lack of insurance to be barriers to treatment. The discrepancies in findings suggest that much research remains to be performed on the relative importance of cost, cultural, and organizational barriers, and poverty and income limitations across the spectrum of racial and ethnic and minority groups.
The World Health Organization’s (WHO) (2005) “Poverty and social exclusion are the greatest threats to their well-being (10). Elderly women are especially disadvantaged due to their marginal position in the society (11)” perspective clearly indicates that the problematic framework of low-income people concerning social exclusion in relation to health care seeking behaviour is ideographic of the difficulties that they interface continuous in their daily lives. Steinman (2004) postulated that African Americans with low incomes and low literacy levels disproportionately suffer poor health outcomes from many preventable diseases. Low functional literacy and low health literacy impede millions of Americans from successfully accessing health information. These problems are compounded for African Americans by cultural insensitivity in health materials. Inaccessible health information also contributes to a higher burden of disease. Many groups encounter obstacles in accessing health information. Low socioeconomic status (SES) African Americans with substandard literacy skills has been shown to suffer excessively from preventable complications of diseases such as breast cancer and diabetes.
In survey in Bangladesh and Vietnam, Ahmed, Tomson, Petzold, & Kabir (2005) conducted a research to elicit information on the health-seeking behaviour of household members over 20 years. It was discovered that socioeconomic indicators were the single most pervasive determinant of health-seeking behaviour among the study population, overriding age and sex, and in case of health-care expenditure, and types of illness. It was discovered that no major differences in health-seeking behaviour between elderly people and younger adults. On average about 35% of those who reported having been ill during the previous 15 days in both age groups chose self-care/self treatment; for both age groups the most commonly consulted type of provider was a paraprofessional such as a village doctor, a medical assistant or a community health worker. Patients’ level of education affected whether they avoided self-care/self-treatment and drugstore salespeople and instead chose a formal allopathic practitioner. Despite the advanced statistical technique (i.e. logistic regression) that used the researcher, they admitted that the findings lack external validity. The sample was particular district in which four localities were chosen. The selected villages were within one district; and these were selected because of the close proximity (3 miles) to a starting point. The findings on the sampled population, therefore, cannot be used to generalized on the population (i.e. Bangladesh); but this research unearth valuable information that forms the basis of for a study in other topologies within the context of the use of probability sampling techniques on the nation (i.e. country).
Case, Menendez, & Ardington, (2005) cited that at older ages, fewer individuals sought treatment at public medical facilities. The use of traditional healers increases among persons who died in their late twenties, of whom almost 60 percent sought care from a traditional healer. Traditional care declines at older ages, and there is a small downward trend in the use of non-prescribed treatment with age. It is therefore evident that care seeking declined above age 60.
Case, Menendez, & Ardington, (2005) examined patterns of health seeking behaviour of some individuals who lived in the Northen KwaZulu-Natal prior to their death. It was discovered that significant positive associations between individuals’ socioeconomic status, measured using household ownership of a variety of durable goods, and their use of medical services. The researchers found out that asset ownership correlate significant to health status and health seeking behaviour. Individuals with greater economic resources are significantly more likely to seek treatment from private doctors, and spend considerably more for all types of health services. Individuals who are ill for a longer period before death are reported to see a greater number of health providers. While almost everyone interacts with Western medicine, those who are ill longer also see traditional healers and take non-prescribed medication. According to Jimba (2002) research when rural Nepalese feel sick, they seek healthcare only when the sickness is moderate and severe. Mild illnesses are treated at home. When the villagers seek health care, they preferred to visit traditional healers first, before visiting other health workers.
Latin America and Caribbean perspectives
Social health must receive focus and intervention. Changing social norms related to violence, avoidable injuries, responsible sexual behaviour, and a clean environment, for example, will become more critical. Use of appropriate interventions: information, communication, legal and fiscal measures and persuasion, will necessitate new ways of working and new partners with whom to work, in the public and private sector (Caribbean Epidemiology Centre, 2000).
The Caribbean Epidemiology Centre’s monograph in its “Annual Report, 2000”is a summation of number of the socio-demographic factors that are of importance in the social research within the context of health. This setting is primarily so because health is beyond the tradition definition of physical ill-health to social and psychological wellbeing of the individual, which include many social conditions that continuously interface the people in their environ. This organization has laid the foundation for an investigation of determinants of health-seeking behaviour of Caribbean nationals. In a study on Jamaican elderly Eldermire highlights a number of socio-economics conditions that determine health-seeking behaviour (Eldemire, 1997). She forwards the perspective that access to health insurance is aids the health-care behaviour of elderly, which concurs with the findings of Ahmed et al. (2005).
Eldemire argues that
The situation of older person in developing countries is largely due to the consequences of social and cultural change in all countries of the third world (Eldemire, 1997, p.76)
The perspective of Eldemire is an illustration of the Caribbean Epidemiology Centre’s stance of the social conditions that are imperative determinants of health-seeking behaviour of Caribbean nationals. Ahmed et al. and other non-Caribbean researchers always uttered those positions. On like the former authors, the latter’s findings are external validity, and so are usable for generalizability of the Jamaican populace. I will apply the conditions that exist in determining health-seeking behaviour of the elderly as a proxy for all other age categorizations.
A research that was done in Mexico which was sponsored by the World Bank revealed a number of findings that were similar to those unearth by Eldemire and Ahmed et al, and other writer, that
Education is likely to increase demand for health services as it raises the
productivity of health production, the household's appreciation of the benefits of better health care, and its potential labor market earnings (Although theoretically education could reduce health service utilization by increasing the opportunity cost of time devoted to health care, most studies show that education have a positive effect, implying that its opportunity cost effect is less than the other putative effects of education.);
The time (distance) it takes to access a health service reduces the use of that service; it may, however, increase the use of other health services, depending on whether they are substitutes or complements;
Health insurance increases demand for health care, since it reduces the price of health service use;
The demand for preventive, curative and other health services can then be expressed as a function of household wealth, the price of health services, the environmental health threats, and other exogenous factors such as education, age and culture that either affect the production function, the resource constraint, or the household's utility function.
. . .health insurance, education, urban-rural residence, and wealth
appear to be significantly positive determinants of perceived health status.
The research carried out in Mexico used probabilistic sampling frame and so is external validity as a tool of generalizability of the people’s social setting. In a critical perusal of findings of the World Bank study on Mexicans, information obtained were on all people, which highlight the issue that the determinants of health-seeking behaviour for adults are those for all concerned. Pan American Health Organization (PAHO) (2003) in one of its presentations concurs with the World Bank, Eldemire, Ahmed et al. and other writers that
The family is the key social institution that joins individuals related by birth or by choice into a household or a domestic unit. The family is the setting where health behaviour and health decisions are first established. In the Americas, cultural factors in families influence significantly on access to, and on health- seeking behaviour; for example, women may assign a lower level of priority to their health needs giving preference to other family needs such as food and education. This priority setting may adversely affect the health of the family; however, it is in the context of the family that this behaviour is best modified;
Families are often a reflection of the community and provide the first level of education for its members about healthy behaviours that should be followed, unhealthy behaviours to be avoided or changed, and their roles and responsibilities to themselves and to society. Sometimes elements in the family setting are not conducive to promoting or protecting the health of some of its members. It is therefore important that the community have family support systems in place in cases where the health of family members is threatened by violence, abuse, neglect, or abandonment.
Within the perspective of PAHO, the determinants of health-seeking behaviour are social, economic and cultural. It should be noted from the viewpoint of PAHO that culture begins the socialization of health-seeking behaviour, and it is through this medium that social and other variables are introduced. With this perspective, the determinants of health-care seeking behaviour of the elderly are the same for other age cohorts. All the writers have agreed with each other that education, access to health care, duration of illnesses, income, social class, and cultural factors determine health-care seeking behaviour of ‘people’. There is a consensus among the sapiential powers that health-seeking behaviour is a function of educational level, gender, age, access to health insurance, household composition, and cultural factors (PAHO; World Bank; Ahmed, et al., 2005, Eldermine, 1997; Caribbean Epidemiology Centre; Case et al. 2005).
Poverty
Many writers who have presented a perspective on the poverty-discourse generally agree that the people involved are primarily only able to survive (i.e. food consumption) because of their financial inadequacies (Henry-Lee, 1995, 2001; PIOJ, 2000; Maxwell, 1999; Haveman 1987; Townsend, 1979). From Henry-Lee’s monograph, ‘food poverty’ and ‘ultra poverty’ befall a number of Jamaicans (Henry-lee, 2001, p.199). Within those two conceptualizations lie the meager existences of people. This social reality represents a miniscule number of people (‘food poverty’ – 5% and ‘ultra poverty’ – 10%) but within the explanation are hidden human sufferings and their inability to accept other social services.
From Henry-Lee’s theorizing, poverty is an implied illustration that can be use to justify the causal relationship of poverty on health-seeking behaviour. The argument is simple: if an individual is primarily preoccupied with food, he/she is highly unlikely to access other social services. Hence, Osei describes a perspective on poverty eradication that includes expenditure on health care, education and other social services. Osei is of the view that social change of the poor is embedded in the acquisition of land, and other transferable position. With the incapabilities of the poor, the researcher is forwarding a thesis that poverty is a determinant of lower health-care seeking behaviour.
Gender differences in health-care seeking behaviour
One writer forwarded the view that socio-cultural conditions influence health behaviour of people; and added that gender is the most significant of them all (Courtenay, 2000; 2002). This situation further predicts the female gender on health promoting behaviour. Many writers, because of this view, establish an association between male and female, and mortality. As a result, mortality differences between the gender and socialization explain heath-seeking behaviour. This social reality is not subjected to a particular topology but is common to ethnicity, nationality and religiosity (Hicks, 2003; Astrachan, 1999). Hick (2003) viewpoint was that men are in the background when it comes to taking care of their health, as they are invariably embarrassed because of the macho socialization process.
Hicks, a medical doctor, helps us to understand how he formulated his perspective on behaviour of men concerning health-seeking. He believes that one of the factors that determine men’s reluctance in health-care behaviour is the ‘misbelief’ that the issue to gradually disappear. This is found complication a number of simple medical conditions into chronic issues that sometimes result in impairment and death. On the other hand, women are highly interesting in ascertain the simplest of matter may is self-unexplainable. Astrachan (1998) concurred with Hicks in his findings that traditional male-gender role helps to cultivate this reluctance in health-seeking behaviour, and this may be costly. Astrachan’s research is on young men between the age cohorts 15 to 17 years in the United States; and so helps us to understand the behaviour of all men. Another potent reason was the matter of ‘homophobiaism’. Men unlike their women counterpart believe that it is feminine to arbitrarily seek health care unless one is ‘really’ ill (i.e. chronically sick). He argues homophobia influences the man by way of discouragement concerning health-care behaviour. Another writer’s view was men who subscribe to the social-gender prescription are relatively unconcern about their health and well-being (Courtenay, 2000).
A number of academics carried out a research on 401 undergraduate male students (in United States) by deductively testing stereotypical male roles in relation to health attitude and other social factors; and they discovered that restrictive emotional attitude of men was able to predict a decrease in help seeking behaviour (Good et al., 1989). Their justification was based on the number of people who actually met to the doctors for preventative. Approximately 66% of those people who visited the health service for psychological help were female. The result that showed one in three women and one in seven men who sought mental health care at some point in their lifetime further compounded this situation. A number of writers cite that traditional masculine attitudes do indirectly influence the men’s willingness to seek psychological assistance, and secondly external interventions (Robertson et al., 1992).
Courtenay (2002) conducted a research on college men and women in respect to ‘Gender Difference in Health Beliefs and Behaviour’ the study were exploratory. From the research, the findings revealed a consistent gender difference with males and females about risky behaviour and the perception of risky behaviour. Men indulge in more risky behaviour than women do, and females are medically compliant. One writer from his research found that American men have only limited contact with physicians and the health care system (Sandman, 2000). The findings did not cease there as many men failed to get routine medical checkups, preventative care, and health counseling, and they often ignore symptoms or delay seeking medical care when they were sick or in pain. This social reality helps to explain the lack of preventative care and the irregular visits to traditional health services. Social taboos or socialization within the context of embarrassment is another factor that explains men’s silence on health issues along with their willingness to discuss such matters.
Henry-Lee et al. (2001) and PAHO (2000) and other research are from different topologies, and the findings converge on a general principle that biomedical conditions are only the only determinants of health-care seeking behaviour of humans. From the slant of the WHO’s definition of health, the variable is multi-dimensional and so include social, cultural and psychological conditions in addition to the tradition perspective on health conditions. All the research from Europe, Africa, United States and Latin America and the Caribbean are testament to the external validity of determinants of health-seeking behaviour of people.
A few writers, in a non-generalizable study in Bangladesh, aptly forward a perspective that justifies the researcher’s willingness to investigate the health-seeking behaviour of Jamaicans.
They wrote:
[Mostly,] people possess imprecise and wrong perceptions about their health. It has been found that people are indifferent to their health needs, and in most cases, they defer or delay treatment by conscious choice when they are sick and need medical support. It is, therefore, important to understand how people perceive their health and health needs, and how and at what stage they decide to go to health providers for treatment or medical consultation (S.M. Nurul Alam, Rasheda Khanam & Shahed Hossain, 2000).
In preparation of topic, which is to determine the causal factors of this research, the researcher analyzed the findings of other academics’ works and writers on the subject matter, based on the literature review, to establish a logistic model. As a result, the researcher forwards this theorizing that health-seeking behaviour is a function of gender, age, union status, poverty, household size, educational level, access to health care, ownership of health insurance, severity of illnesses and duration of illnesses.
Paul Andrew Bourne, MSc.; BSc. Dip. Edu.
Research Assistant
Department of Management Studies
University of the West Indies
Mona Campus
Kingston, Jamaica
West Indies