Health-care-seeking behaviour in patients with hypertension: experience from a dedicated hypertension centre in Bangladesh

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Introduction
Hypertension is a leading public health problem in the world.It is one of the most important causes of premature deaths and loss of healthy life years [1].Worldwide, approximately 626 million men and 652 million women were suffering from hypertension in 2019 and the number continues to rise [2].Bangladesh is going through an epidemiologic transition from communicable to non-communicable disease (NCD).
There is an increasing prevalence of hypertension accompanying NCDs.In 2020, the estimated prevalence of hypertension in Bangladesh was 20% [3].
Despite the life-threatening implications of hypertension, the proportion of patients achieving blood pressure control remains less than 25% [2].Patients' use and continuation of anti-hypertensive medication may vary across countries and depend on the country's socioeconomic, health policy and practice-related factors [4].In rural Bangladesh, nearly one-quarter of those diagnosed as hypertensive and started with anti-hypertensives were found to discontinue medication within a few days [5].Being suspected and treated as hypertensive by unqualified providers was significantly associated with non-adherence to medication for hypertension in Bangladesh [5].Therefore, the treatment of hypertension is partly determined by the centres from which the treatment is sought.Hypertension care in Bangladesh is usually provided by registered medical doctors in all tiers of public health deliveryfrom primary health centres like Upazila Health Complex (UHC) to specialised tertiary care hospitals in private hospitals and chambers.However, semi-qualified or unqualified informal providers like pharmacists (i.e.drug sellers), 'village doctors' , 'kabiraj' (persons using a mixture of herbs and traditional knowledge to provide health care) or 'spiritual healers' are the popular first choice for seeking health advice [6].Selling of anti-hypertensives is not well regulated.Therefore, people can even buy anti-hypertensive drugs without a prescription.The diagnosis and treatment of hypertension are provided by physicians mainly through personal consultation in a hospital outdoors or at a hospital outdoors.However, the diagnosis might be incidental during consultation or at admission to the hospital due to other illnesses.A few dedicated centres actively monitor the treatment of hypertensive patients.
Patients' health-seeking behaviour (HSB) related to hypertension also plays an important role in determining adherence to treatment [4].HSB is any activity undertaken by an individual who has a perceived health problem or illness to find an appropriate remedy; it depends on patients' knowledge, socioeconomic factors and accessibility of healthcare services [7].Patients diagnosed with hypertension may present with a variety of symptoms.Most people remain asymptomatic for a long time without being aware of their hypertensive status [8].Hence, the HSB of hypertensive patients might also depend on the clinical manifestation.The expected HSB from patients with suspected hypertension is to consult formal (i.e.working in public hospitals) or registered healthcare providers for their problems [9].However, that is often different from the real-world scenario.Some people seek care from informal providers first before coming to registered physicians.They often go to local pharmacies to check blood pressure and get their treatment started if pressure readings are high.While others prefer to consult physicians at their private chambers or go to the hospital outdoors for initial check-up.The presence of a dedicated hypertension centre might lead aware people to go directly to the centre for their initial consultation.
Nevertheless, different factors might play their role behind the decision to seek care for hypertension.Previously, qualitative assessments of HSB in Bangladesh identified that patients' beliefs, economic status and health care provisions are important drivers of HSB related to hypertension and other NCDs [6,10].This study aimed to quantitatively assess the health-seeking pattern and explore the important factors associated with HSB among hypertensive patients in Bangladesh.

Study design, settings and population
This cross-sectional study was conducted in the Hypertension and Research Centre, Rangpur, Bangladesh, between January 2022 and June 2022.All adults (>18 years) diagnosed with hypertension according to the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8) guidelines [11] were consecutively selected for inclusion.Pregnant women and or patients unwilling to participate were excluded.We calculated the sample size using the formula n z pq d = 2 2 .As no quantitative measure of HSB in Bangladesh was available from the literature, assuming a 50% prevalence (p) of health-seeking practice from informal providers, 'q' equal to '1 -p' , 95% confidence interval (z = 1.96), 5% margin of error (d), and 10% non-response rate the sample size was calculated to be 422.However, a total of 497 patients were included during the study period.

Data collection method
Data was collected using a pre-tested structured questionnaire.It was pretested in a sample of twenty patients in the hypertension centre.Then, the questions were adjusted based on the observations.The questionnaire was prepared after an extensive literature review, which asked the patients about their sociodemographic profile (including age, sex, religion, residence, employment status and household characteristics), personal habits (including smoking habit, history of alcohol intake, history of drug abuse, physical activity, Television (TV) watch time and sleeping habit), information related to hypertension and HSB (mode of diagnosis, how suspicion of hypertension arose, family history of hypertension, measures taken for high blood pressure, causes/symptoms compelling to consult with health care professionals, whom they consulted first for the symptoms, previously diagnosed case/new case, clinical presentation at the time of the interview, duration of clinical manifestation), comorbidity profile and drug history.In case of previously diagnosed patients, their follow-up books were consulted to validate their symptom description at the time of first diagnosis.Patients' blood pressure was measured using an appropriately calibrated manual aneroid sphygmomanometer and arm cuffs.The initial measurement was performed after 5 min (mins) of rest at the seating position in the right arm.Then, after 2 min, the second measurement was taken in the left arm.Then again, 5 min after the second measurement, a third measurement was taken in the right arm.Trained nurses obtained three measurements to diagnose new hypertensive patients.Also, three measurements were performed to record the status of blood pressure for previously diagnosed patients on the day of data collection.All the measurements were recorded in the questionnaire.

Hypertension
The mean values of three blood pressure measurements were taken to assess blood pressure status.A systolic blood pressure (SBP) of ≥140 mm of Hg and/ or a diastolic blood pressure (DBP) of ≥90 mm of Hg was considered diagnostic for hypertension based on the JNC 8 guideline [11].Blood pressure was considered controlled when the SBP and DBP were between 80-139 and 60-89 mm of Hg, respectively.

Healthcare seeking behaviour
It is the behaviour of people who perceive themselves to be ill for seeking remedies to return to normal health.Here, healthcare seeking behaviour was assessed in terms of to whom the patients access their healthcare.

Case type
Patients who were previously registered and treated in the Hypertension and Research Centre, Rangpur were considered diagnosed cases.Patients diagnosed with hypertension for the first time in the centre were considered new cases.

Provider type
Registered physicians and trained nurses of the hypertension centre were deemed formal providers.Untrained health care providers, including village doctors (homoeopathic and allopathic), drug vendors, traditional birth attendants, 'Kabiraj' and religious/ spiritual healers, including the patient himself/herself, were identified as informal providers [12].The non-physicians, including other nurses or medical technologists who are not trained in treating hypertension, were also grouped with informal providers in the context of hypertension management.

Self-measurement and self-provider
When a person measured his/her own blood pressure using a fully or semi-automated blood pressure measuring machine (also known as a digital blood pressure machine), the measurement was considered a 'self ' measurement.If the person chose the medication on his/her own based on his/her knowledge gained through experience with friends or relatives, or through reading from different sources, he/she was considered a 'self ' provider for anti-hypertensive treatment.

Sedentary activity
The extent of day-to-day activities' physical movements was considered sedentary.

Central obesity
A waist circumference of more than or equal to 80 cm and 90 cm were considered central obesity for females and males [13], respectively.

Statistical analysis
After data entry and curation, descriptive and analytic statistics were carried out.Categorical data was presented as frequency (percentage) and continuous data as mean ± standard deviation.Independent samples t-test was used for comparison of continuous variables.Fisher's exact test and Chi-square test were used for analysis between two categorical variables.Univariate and multivariable logistic regression analysis was carried out to explore factors associated with health-seeking practice from informal health care providers.All statistical analysis was carried out in SPSS version 24 (SPSS Inc., Chicago, IL).A p value of < 0.05 was considered significant for all statistical test.

Ethical measures
This study was approved by the Ethics Review Committee (ERC) of Dhaka Medical College.All procedures were undertaken following the guidelines of the Declaration of Helsinki.Informed written consent was taken from every patient before inclusion.

Results
Table 1 describes the characteristics of the study participants.The average age of patients was 51.7 ± 10.8 (SD) years, and most of them were aged between 51 and 60 years (32.8%).The proportion of males and females was, respectively, 45.5 and 54.5%, with a male:female ratio of 1: 1.12.Most of the patients came from rural areas (56.8%), had primary education (23.6%), were homemakers (55.4%) and were from middle economic class (68.2%).Of all, 85.9% were never smokers, 10.5% were past smokers and 3.6% current smokers.Most patients had moderate-intensity physical activity habits (51.1%).However, nearly two-fifths of patients (42.1%) were doing sedentary activity and 71.9% had a family history of hypertension.The most common comorbidity was central obesity (46.0%), followed by diabetes mellitus (23.0%).Most patients had symptoms associated with hypertension for a duration of 6-12 months (51.3%).Blood pressure was uncontrolled in 37.6% of patients with or without medications.
More than one-quarter of patients (26.56%) initially consulted informal healthcare providers for hypertensive symptoms (Table 2).The first blood pressure measurement leading to a diagnosis of hypertension was predominantly done by a registered physician (52.5%).This was followed by nurses of hypertension centre (21.3%), village doctors (13.7%),Multivariable logistic regression analysis showed that every five years increase in age was associated with 22% lower odds of consulting informal providers (aOR: 0.78, 95% CI: 0.68 − 0.89).Compared to females, male patients were 1.79 times (95% CI: 1.05 − 3.10) more likely to seek health care from them.Patients living in semi-urban areas were 4.68 times (95% CI: 1.45 − 15.10) and those living in rural areas were 1.68 times (95% CI: 1.01 − 2.80) more likely to go to informal health care providers than those in urban areas.Farmers had 3.24 times (95% CI: 1.31 − 8.06) higher odds of going to informal providers.Patients from lower economic class were significantly more likely than those from higher class (aOR: 4.24, 95% CI: 1.68 − 10.69) to go informal healthcare givers (Table 3).

Discussion
Hypertension is one of the primary chronic conditions which cause considerable morbidity and mortality.The people of Bangladesh have a high prevalence of hypertension [3], which is rising rapidly as the country is going through an epidemiologic transition.However, patients often seek health care from unqualified informal providers when symptoms suggestive of hypertension appear for the first time.We explored the patterns and determinants of such HSB among hypertensive patients in northern areas of Bangladesh.
Patients were, on average, quinquagenarian, and the majority were female similar to findings from other areas of Bangladesh [5,7] and the whole country [3].A high prevalence of hypertension in women is usually noted in low-and middle-income countries [2].
In this study, the blood pressure control rate (62.4%) of participants was much higher than that (14.1%) found in the World Health Organisation STEP-wise approach to NCD risk factor surveillance (STEPS) conducted in 2018 in Bangladesh [14].The difference could be explained by the fact that our participants were recruited in the hypertension centres and nearly four-fifths of them were previously diagnosed cases.Therefore, it is expected that their blood pressure was brought under control through monitoring of treatment in the centre.
In this study, the proportion of smokers was low despite it being a significant risk factor for hypertension [15].This probably reflects a higher proportion of female in our sample, only 1% of whom smoke in Bangladesh [14].More than two-fifths of our patients were sedentary workers and nearly half of them had central obesity (i.e.high waist circumference).Low physical activities and a high waist circumference have proven associations with hypertension [15][16][17][18], which relates to our findings.Half of the patients came directly to the study centre (Hypertension & Research Centre, Rangpur, Bangladesh) after the appearance of symptoms suggestive of hypertension.Also, hypertension was suspected and/or diagnosed in more than two-thirds of the patients by registered physicians and trained hypertension centre nurses (formal health providers).This number is remarkably high and reflects the population pattern of HSB for NCDs in the Rangpur region [6].In comparison, a previous study found that one-third of the urban population in Dhaka and less than one-fifth of the rural population in Matlab, Chandpur, sought medical care from registered MBBS doctors for hypertension [19].This difference could be probably because the Hypertension & Research Centre is a well-known centre for hypertension management in the Rangpur region which provides treatment facilities at a low cost.Hence, people in this region might have decided to visit the centre instead of visiting informal providers.In addition, the availability of affordable facilities within reachable distance could provide people with an option to go to registered physicians.Previous studies conducted in rural India [20] and Bangladesh [10] endorse this fact where the distance to the health facility was one of the multiple factors discovered to influence people's choice to take service.
Among the other factors, our analysis revealed that age, sex, residence, education, occupation and economic status were significant determinants of HSB.Patients who were young, male, residing in rural or semi-urban areas, farmers and from lower socioeconomic classes were significantly more likely to take service from informal providers after the first appearance of their symptoms.Every five-year increase in age was associated with 22% (95% CI 11 − 32%) decreased odds of taking care from informal providers, indicating that diagnosed patients were more likely to be taken to formal providers after the appearance of their symptoms.This can be explained in the context that supporting the elderly members is a dominant practice in South Asian families [21].
Jahan et al. [7], in a study conducted among rural hypertensive women, reported that the main barriers perceived by the participants in taking service from health care centres were economic dependencies on husbands, lack of permission to go alone and low economic solvency.Interestingly, however, in our study, we found that female patients were more likely than males to go to formal providers after their symptoms appeared and the association was independent of other factors.A similar picture was discovered by Uddin et al. [19] among urban patients suffering from hypertension.Male patients of our study, particularly those with enough income, probably prioritised their families to get care from formal providers.This assumption also makes sense when we consider that farmers, patients with no education and those from low socioeconomic strata were significantly more likely to seek health from unregistered providers in our study.This also implies that the main determinant of HSB is economic capacity of a family.In fact, many previous studies from different countries confirm that one of the fundamental factor influencing HSB from formal providers is the economic capacity and cost of the treatment [6,7,20,22,23].Being a chronic disease, treatment of hypertension incurs a high cost, which has to be maintained for a long time.As a result, poor people are left with no choice but to prefer spending for basic needs rather than for the management of hypertension [23].In Bangladesh, out-of-pocket expense accounts for as much as 72.68% of health expenditure [24].An annual estimated cost of US$ 3.2 million was estimated for hypertension control in Bangladesh, out of which 43% was attributed to the cost of medications [25].Therefore, it is difficult for low-and middle-income people to cope with healthcare costs.Hence, a policy-level reform of the healthcare financing system is required to meet the needs of hypertensive patients at all levels.
We found that rural and semi-urban patients were more likely to go to informal providers than urban patients, which is explainable in terms of economic status.In addition, interpersonal relationships with informal providers often persuade patients to seek advice [6].This is mainly true for rural and semi-urban inhabitants, where people live in close interactive communities and where informal providers are known persons from within the community and are available round the clock.However, as all of our participants ultimately came to Hypertension & Research Centre with the majority being out of fear of stroke, we can reasonably argue that people, if made aware of the importance of controlling blood pressure, would seek health care from formal health care providers for their hypertensive symptoms.
Our study had several limitations.First, factors influencing the HSB of hypertensive patients, including the distance of health care centres, quality of service provided and costs of service taken, remained unexplored in this study.Second, the study was based on patients registered in the Hypertension & Research Centre.Therefore, patients who did not reach the centre even after having high blood pressure readings were missed, leading to potential selection bias.These may include those unaware of the centre, not referred by the consulting physicians or not compliant with their physician's advice to reach the centre for follow-up.Third, this study only involved patients from one centre in the North-Eastern part of the country and might not accurately represent other regions of the country.Fourth, a qualitative assessment of HSB was beyond the scope of this study.

Recommendations
Keeping the context of this study and findings of previous qualitative assessments of HSB into account and based on the results of our study, we have the following recommendations.Specialised centres with the availability of health services for hypertension at an affordable cost should be established in all districts.The NCD corners of UHCs could be used as a hub for hypertension treatment and monitoring at the primary health care level.Non-physician healthcare workers could be trained to refer patients to hypertension centres (or NCD corners) for optimum care.Essential drugs for hypertension should be provided and ensured at low cost at community clinics.Community-based health education and promotion programmes should be implemented to increase awareness about the importance of appropriate HSB for hypertensive care.

Conclusion
This study found that less than one-third of patients with hypertension sought health care from informal providers on their first visit, and younger age, male sex, rural/semi-urban residence, absence of formal education and lower economic status had independent associations with such behaviour.The findings of this study would be helpful for selecting potential candidates for behavioural change communication programmes and designing health education methods and media to influence the HSB of people.Moreover, policymakers and health managers could consider the determinants of hypertension-related HSB during the planning and implementation of hypertension-care delivery through public and private hospitals around the country.

Table 1 .
Characteristics of the participants.
All percentages were calculated after excluding missing systems.

Table 2 .
Health-seeking behaviour of patients in relation to hypertension.

Table 3 .
logistic regression analysis of factors influencing health-seeking practice from informal health providers.