title: Perceived morbidity, healthcare-seeking behavior and their determinants in a poor-resource setting: observation from India.
abstract: BACKGROUND
  To control the double burden of communicable and non-communicable diseases (NCDs), in the developing world, understanding the patterns of morbidity and healthcare-seeking is critical. The objective of this cross-sectional study was to determine the distribution, predictors and inter-relationship of perceived morbidity and related healthcare-seeking behavior in a poor-resource setting.
  
  
  METHODS
  Between October 2013 and July 2014, 43999 consenting subjects were recruited from 10107 households in Malda district of West Bengal state in India, through multistage random sampling, using probability proportional-to-size. Information on socio-demographics, behaviors, recent ailments, perceived severity and healthcare-seeking were analyzed in SAS-9.3.2.
  
  
  RESULTS
  Recent illnesses were reported by 55.91% (n=24,600) participants. Among diagnosed ailments (n=23,626), 50.92% (n=12,031) were NCDs. Respiratory (17.28%, n=7605)), gastrointestinal (13.48%, n=5929) and musculoskeletal (6.25%, n=2749) problems were predominant. Non-qualified practitioners treated 53.16% (n=13,074) episodes. Older children/adolescents [adjusted odds ratio for private healthcare providers (AORPri)=0.76, 95% confidence interval=0.71-0.83) and for Govt. healthcare provider (AORGovt)=0.80(0.68-0.95)], females [AORGovt=0.80(0.73-0.88)], Muslims [AORPri=0.85(0.69-0.76) and AORGovt=0.92(0.87-0.96)], backward castes [AORGovt=0.93(0.91-0.96)] and rural residents [AORPri=0.82(0.75-0.89) and AORGovt=0.72(0.64-0.81)] had lower odds of visiting qualified practitioners. Apparently less severe NCDs [acid-peptic disorders: AORPri=0.41(0.37-0.46) & AORGovt=0.41(0.37-0.46), osteoarthritis: AORPri=0.72(0.59-0.68) & AORGovt=0.58(0.43-0.78)], gastrointestinal [AORPri=0.28(0.24-0.33) & AORGovt=0.69(0.58-0.81)], respiratory [AORPri=0.35(0.32-0.39) & AORGovt=0.46(0.41-0.52)] and skin infections [AORPri=0.65(0.55-0.77)] were also less often treated by qualified practitioners. Better education [AORPri=1.91(1.65-2.22) for ≥graduation], sanitation [AORPri=1.58(1.42-1.75)] and access to safe water [AORPri=1.33(1.05-1.67)] were associated with healthcare-seeking from qualified private practitioners. Longstanding NCDs [chronic obstructive pulmonary diseases: AORPri=1.80(1.46-2.23), hypertension: AORPri=1.94(1.60-2.36), diabetes: AORPri=4.94(3.55-6.87)] and serious infections [typhoid: AORPri=2.86(2.04-4.03)] were also more commonly treated by qualified private practitioners. Potential limitations included temporal ambiguity, reverse causation, generalizability issues and misclassification.
  
  
  CONCLUSIONS
  In this poor-resource setting with high morbidity, ailments and their perceived severity were important predictors for healthcare-seeking. Interventions to improve awareness and healthcare-seeking among under-privileged and vulnerable population with efforts to improve the knowledge and practice of non-qualified practitioners probably required urgently.
authors.affiliation: National Institute of Cholera and Enteric Diseases, Kolkata, 700010, West Bengal, India.
authors.forename: Suman
authors.initials: S
authors.lastname: Kanungo
authors.affiliation: National Institute of Cholera and Enteric Diseases, Kolkata, 700010, West Bengal, India.
authors.forename: Kalyan
authors.initials: K
authors.lastname: Bhowmik
authors.affiliation: National Institute of Cholera and Enteric Diseases, Kolkata, 700010, West Bengal, India.
authors.forename: Tanmay
authors.initials: T
authors.lastname: Mahapatra
authors.affiliation: National Institute of Cholera and Enteric Diseases, Kolkata, 700010, West Bengal, India.
authors.forename: Sanchita
authors.initials: S
authors.lastname: Mahapatra
authors.affiliation: Medical College, Malda, 732101, West Bengal, India.
authors.forename: Uchhal K
authors.initials: UK
authors.lastname: Bhadra
authors.affiliation: National Institute of Cholera and Enteric Diseases, Kolkata, 700010, West Bengal, India.
authors.forename: Kamalesh
authors.initials: K
authors.lastname: Sarkar
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D004194:Disease / Q000145:classification* / Q000208:ethnology / Q000523:psychology; D005260:Female; D006801:Humans; D007194:India / Q000208:ethnology; D007223:Infant; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D010342:Patient Acceptance of Health Care / Q000208:ethnology / Q000523:psychology*; D011203:Poverty / Q000523:psychology; D012424:Rural Population; D012959:Socioeconomic Factors; D055815:Young Adult