Health-seeking behaviour of stroke patients in a rural area of Bangladesh

Background: Improper health-seeking behaviours (HSB) have been correlated with detrimental health outcomes, elevated rates of illness and mortality. The study aimed to inves�gate how stroke pa�ents in a rural community of Bangladesh seek health care. Methods: A cross-seconal survey was conducted in the Raiganj sub-district of Sirajganj district from January to June 2016, using a validated screening tool to iden�fy stroke pa�ents at the household level. Neurologists conﬁrmed the diagnosis a�er examining all suspected cases. Out of the 419 suspected cases iden�ﬁed during the screening process, 186 cases were oﬃ-cially reported a�er undergoing a conﬁrmed diagnosis. Informa�on on health-seeking behaviour was collected through face-to-face interviews with pa�ents or their a�endants. Results: A�er experiencing a stroke, approximately 35% of pa�ents received treatment from unregistered care providers and over 40% received treatment outside of a hospital se�ng. Males were signiﬁcantly more likely than females to receive treat-ment from registered physicians or hospitals ( P <.05 and P <.01). A signiﬁcantly higher propor�on of educated individuals sought healthcare from registered physicians or hospitals (P<.05). Although be�er health-seeking behaviour was observed among higher-income groups, the ﬁndings were not sta�s�cally signiﬁcant. Around 67% of pa�ents were found to be hypertensive, with about one-third of them not taking any medica�on for their elevated blood pressure. Approximately 37% of pa�ents had elevated blood glucose levels but only 22% were taking medica�on. Conclusion: A notable propor�on of stroke pa�ents in rural Bangladesh sought treatment from unqualiﬁed service providers. Health-seeking behaviour was associated with factors such as gender, educa�on, and economic condi�on.

INTRODUCTION mortality after stroke is nearly twice as high as for those without stroke. 8 The psychological and physical wellbeing of patients and their families is significantly affected by stroke, particularly among the elderly, as it is a leading cause of disability. 8 The consequences can be reduced by providing proper care; for that, it is necessary to seek care from a qualified healthcare provider.
When seeking healthcare, most people choose and seek care based on the symptoms or signs of a disease they experience. The behaviour of individuals involves a process of perceiving and judging symptoms after experiencing physical discomfort. 9 However, in Bangladesh, there is inadequate information available on the health-seeking behaviour of stroke patients. 10 Therefore, this study was designed to explore the health -seeking behaviour of individuals who have experienced a stroke in a rural community of Bangladesh.   Around 2% of the patients were taking anti-lipid and anti-platelet medication prior to the stroke, which increased to about 17% after the stroke. None of the patients were taking any anti-ischemic medication before the stroke, but this increased to 2.3% after the occurrence of the stroke (FIGURE 1).

A community-based household survey was conducted in
The study found that around 46% of the patients were given dietary advice by their physicians, while approximately 40% were advised to exercise regularly.
Furthermore, 27% of the patients reported being advised to quit smoking, and 26% mentioned receiving advice to lose weight (FIGURE 2).

DISCUSSION
Adopting appropriate health-seeking behaviour is of paramount importance as it plays a vital role in facilitating early diagnosis and effective treatment, ultimately resulting in decreased complications associated with the disease. 11 This study focuses on analysing the health-seeking behaviour of stroke patients within a rural community of Bangladesh.
In this study, it was observed that a significant proportion, exceeding one-third of stroke patients opted for treatment from unregistered physicians, while more than 40% did not seek any hospital-based treatment.
Conversely, a separate hospital-based study conducted

FIGURE 1 Percentage distribution of patients by medication practice (n=173)
in Bangladesh demonstrated a slightly improved healthseeking behaviour among stroke patients. 10 Nevertheless, this discrepancy can be attributed to the fact that our study primarily took place in a rural setting. Another study, specifically focusing on burn patients in a rural area, revealed that approximately 60% of patients sought healthcare from unqualified healthcare providers. 12 The inadequate health-seeking behaviour observed in rural areas can be attributed to several factors including a lack of understanding regarding the consequences of diseases, limited knowledge about available healthcare facilities, and limited accessibility to healthcare services. 5,10 When comparing Nepal to Bangladesh, it was observed that seeking healthcare for stroke was more favourable in Bangladesh. This contrast can be attributed to the fact that many stroke patients in rural areas of Nepal often choose traditional healers over seeking appropriate medical treatment. 13 The choice of healthcare provider following a stroke incident was found to be influenced by factors such as sex, education, and income. Notably, there was a distinct disparity in health-seeking behavior between male and female patients. A significantly higher proportion of males sought healthcare from registered physicians or hospitals compared to females. This observed pattern of health-seeking behavior among the sexes aligns with findings from other studies conducted in Bangladesh. 14 However, in the context of children with burn injuries in Bangladesh, no significant association was discovered between sex and the pattern of health-seeking behavior. 12 The health-seeking behaviour of stroke patients was influenced by education and income levels. A higher proportion of educated individuals (P<.02) and those with higher income (P<.06) were found to seek healthcare from registered physicians or hospitals. However, the association between income and health-seeking behaviour did not reach statistical significance. These findings align with other studies conducted in Bangladesh which also identified both income and education as contributory factors in determining healthseeking behavior. 14 The study revealed that stroke patients in rural areas of Bangladesh exhibited insufficient practice and awareness regarding stroke risk factors. This observation aligns with a similar trend identified in rural communities in Pakistan. 17 This study revealed that over two-thirds of the patients had hypertension, yet approximately one-third of them were not receiving any medication for its management. Furthermore, around 37% of the patients were found to have diabetes, but only about one-fifth of them were actively taking medication to control their high blood glucose levels.
Similar practices were observed among patients with hypertension and diabetes in India. 18 One limitation of this study is that it predominantly focused on a rural population at the subdistrict level which may not accurately reflect the health-seeking behaviour of the urban population in Bangladesh, hence lacking generalization. However, the strength of the study lies in its inclusion of the entire population aged 15 years and above in a specific geographical area, who were under a health and demographic surveillance system. Additionally, the confirmatory diagnosis of stroke was made by senior neurologists from the National Institute of Neurosciences and Hospital, Bangladesh.