Factors influencing health

seeking behavior of the elderly

on non-communicable diseases

in Pyay Township

Aung-Kaung-Khant, Cho-Mar-Htwe, Nyein-Thu,

Kaung-Myat-Oo,Toe-Pyae-Thandar-Htun, Nu-Kaythi-

San, Thida-Aung, Myat-Su-Khine, Mya-Thandar

1

47th Myanmar Health Research Congress

7th January 2019

Presentation outline

• Introduction

• Objective

• Methodology

• Findings

• Discussion

• Recommendations

• Acknowledgement

• References

2

Introduction • Non-communicable diseases (NCDs) about 60% of

global deaths (38 millions) (WHO, 2014)

• All ages at risk of NCDs but disproportionately affected

in older people (Department of population, 2016)

• In Myanmar, elderly (65 yrs and above) 5.8% of total

population (Census, 2014)

• WHO estimates that NCDs account 40% of all deaths

(WHO, 2017) and Hypertension prevalence increases to

52% in 60-69 years age group and 60% among 70 years

and above (Ko-Ko-Zaw et al., 2011)

• In spite of increasing aging populations, health services

provided are still limited (Myint-Han, 2012)

• Impose great burden on health system 3

General objective • To determine the factors influencing health seeking

behavior of the elderly on NCDs in Pyay Township

Specific objectives • To find out the proportion of the elderly with NCDs

• To identify the factors influencing health seeking

behavior of the elderly on NCDs

• To describe the pattern of health seeking behavior

4

Methodology

Study design

• Cross sectional study

• Conducted in Pyay Township in 2018

Study population

• elderly people of 60 years and above at the time of data

collection.

Sample size

• assumption of a 64% proportion of elderly person who

utilized private and public health care services (Aye-

Lwin, 2015)

• 95% confidence with 90% power and cluster effect 1.5

• Total sample size was 272 but actually 303 were

collected to compensate drop out effect 5

Sampling procedure

6

4 wards (45%) Random sampling

Systemic sampling

•If 2 eligible respondents in one HH, select one with elder age

•If no elderly in selected HH, select adjacent HH

Pyay Township

6 villages (55%)

35 Households

from each ward

27 Households

from each village

Total 303 elderly

Data management and analysis

• Face to face interview was conducted with pretested

questionnaires

• interviewers were trained

• Data entry by EpiData 3.1

• Data analysis by using SPSS software

• 95% CI of NCDs proportion was estimated

• Significant factors (p value <0.25 in bivariate analysis)

were undergone for multiple logistic regression analysis.

• P value of 0.05 was used as the level of significance

7

Ethical considerations

• study proposal was approved by Institutional Review

Board of University of Public Health

• with the certificate of approval letter UPH-IRB

(2018/MPH-G/1)

• The interview was conducted only after getting informed

consent.

8

Findings

9

10

5.9%

49.2%

3.3%

41.6%

Single

Married

Separated/Divorced

Windowed

62.0%

22.4%

12.9%

2.6%

Dependent

Self-employee

Retired

Employee

Figure (1) Marital status (n=303) Figure (2) Occupational

condition (n=303)

12.2%

41.6%

28.7%

11.9% 2.0% 1.0% 2.6%

Figure (3) Educational status (n=303)

11

46.9%

21.5%

12.9%

11.9%

6.9%

Son/Daughter

Him/Herself

Spouse

Son/Daughter-in-law

Relatives

Figure (4) Major breadwinner in family (n=303)

40.9%

24.4%

17.8%

7.6%

4.0%

2.6%

1.3%

1.3%

Daughter

Spouse

Son

Relatives

Grandchildren

None

Son/Daughter-in-law

Non relatives

Figure (5) Main care giver support for elderly (n=303)

12

57.4% had at

least one

of major

NCDs

86%

12.6%

12.0%

0.8%

Hypertension

Chronic repiratory disease

Diabetes mellitus

Cancer

Figure (6) Type of NCDs (n=174)

Among 303 elderly in Pyay Township,

95%CI of proportion of NCDs = 52% - 63%

*Each respondent may have more than one of major NCDs

13

Having proper health seeking behavior

• Elderly who seek medical professionals health services in

all steps and undergo regular follow up to these services

Medical professional service

• hospitals, private clinics, general practitioner clinic, elderly

clinic, UHC, RHC and SC

Non medical professional service

• drug stores, traditional clinics, non-licensed practitioners

14

STOP

Medical Professional service

Improper health seeking behavior

Proper health seeking behavior

Non-medical Professional service

STOP STOP

STOP STOP

24

83

4 148 41

34

21 2

5 5 14

26

3

Total

174

1st step 2nd step 3rd step

HSB regardless of follow up status

Proper HSB = 83+34+4 = 121

Improper HSB =5+14+5+2+3+24 = 53

HSB including follow up status

Proper HSB = 121-26 = 95

Improper HSB = 53+26 = 79

Figure (7) Pattern of health seeking behavior on NCDs among

the elderly

15

121 69.5%

53 30.5%

Improper

HSB

Proper

HSB

95 54.6%

79 45.4%

Improper

HSB

Proper

HSB

Figure (8) Health seeking behavior on NCDs among the elderly

After accounting follow up status

16

44.3%

14.9%

10.9%

7.5%

5.2%

1.1%

1.1%

13.8%

0.6%

0.6%

GP clinic

Private clinic

Sub center

UHC/RHC

Hospital

Elderly clinic

Charity clinic

Pharmacy Traditional clinic

Other

Traditional clinic Number Percentage

Reasons for proper health seeking behavior (n=95)*

Easily accessible

Trust and belief

Familiar with care provider

50

41

35

51.6

43.2

36.8

Reasons for improper health seeking behavior (n=53)*

Suitable price

Personal own choice

29

22

54.7

41.5

*multiple choice

Figure (9) Choice of Health facility for 1st step seeking (n=174)

17

Variable no. (%) COR(95% CI) AOR (95% CI) p value

Education status

High education

Low education

35 (20.1)

139 (79.9)

1

4.29 (1.76-10.49)

1

4.74 (1.89-11.86)

0.001*

Marital status

Without spouse

With spouse

89 (51.1)

85 (48.9)

1

1.65 (0.90-3.02)

1

2.05 (1.08-3.90)

0.001*

No. of family

members

≥ 4 persons

< 4 persons

109 (62.6)

65 (37.4)

1

1.56 (0.84-2.89)

1

1.55 (0.80-2.98)

0.186

Age

≥ 68 years

< 68 years

92 (52.9)

82 (47.1)

1

0.89 (0.49-1.62)

0.708

Sex

Female

Male

115 (66.1)

59 (33.9)

1

1.39 (0.74-2.61)

0.302

Residence

Rural

Urban

89 (51.1)

85 (48.9)

1

1.25 (0.68-2.27)

0.463

Occupation

Independent

Dependent

63 (36.2)

111 (63.8)

1

0.96 (0.51-1.78)

0.900

*significant level (p value < 0.05)

Factors associated with improper health seeking behavior on NCDs

(n=174)

Discussion

18

Discussion – proportion of NCDs

among the elderly • HT(86%), DM(12%), CRD(13%), cancer (1%)

• HT(38%), CVD(13%), CRD(8%), DM(5%) Elderly

Survey Myanmar (Rajan and Sreerupa, 2017)

• HT(56%), MSD(26%), CVD(24%), DM(13%) Kalaw

(Aye-Lwin, 2015)

• There may be large proportion of hidden cases

• PEN projects start to implement in Myanmar (NCDs

National strategic plan 2017-2021)

• But not in Pyay Township

Ht – hypertension DM – diabetes mellitus

CRD – chronic respiratory disease CVD – cardiovascular disease

MSD – musculoskeletal disease

PEN - Package of essential non-communicable diseases 20

Discussion – Utilization of health

services

• GP(44%), RHC/SC(18%), private(15%), pharmacy(14%), elderly clinic(1%)

• Private(26%), GP(21%), RHC/SC(17%), hospital(13%) Elderly survey Myanmar (Rajan and Sreerupa, 2017)

• Elderly clinic(50%), GP(21%), self(15%), hospital(12%) Kalaw (Aye-Lwin, 2015)

• Low utilization of elderly clinics

• RHC/SC not main choice

• Elderly clinic opened in all RHC/SC on every Monday in Pyay

GP –general practitioners

RHC – rural health center

SC – sub center 21

Discussion - Factors influencing

health seeking behavior (HSB)

In the study of Myanmar (Soe-Moe et tl., 2012),

• Sex, ethnicity, religious no association

• Below poverty line skip treatment↑

• Low education status skip treatment↑

• no. of members, age, sex, residence no association

• Low education status improper HSB ↑

• Living with spouse improper HSB ↑

• 41% of married elderly didn’t get any care giver support from their son and daughter

• Need to explore more on family and social support 22

Strength • Pattern of health seeking behavior could be clearly seen in

this study.

• Many previous literatures mentioned only first step of

utilization of health services.

Limitation • Behaviors related to communicable diseases and current

illness could not be assessed

• Study emphasized on major NCDs

• NCDs cases among the elderly was only self-reported

status without diagnostic measurement.

23

Recommendations 1. The submerged portion of NCDs among the elderly

population should be investigated

24

Recommendations (cont.) 2. Package of essential non-communicable diseases (PEN)

project should be established and promoted all over the

country.

25

Recommendations (cont.) 3. Health literacy about NCDs and ageing should be

strengthened

26

Recommendations (cont.) 4. Elderly clinics should be prioritized and upgraded in

health facilities

27

Recommendations (cont.) 5. Further studies to identify NCDs risk factors and factors

related to the occurrence and consequences of NCDs

among the elderly.

28

Acknowledgement

I would like to express our heartfelt thanks and profound

gratitude to

• Professor Khay Mar Mya

• Associate Professor Dr Mya Thandar,

• Dr Thida Aung, and Dr. Myat Su Khine

• All 13 members of Group 1 from MPH 11th Batch

• All elderly people and everyone participated in our study

30

References

Aye-Lwin. Common Health Problems And Health Care Seeking

Behaviors Of Elderly In Kalaw Township. MPH. University of

Public Health, Yangon 2015.

Department of population, Ministry of Labour, Immigration and

Population. The 2014 Myanmar population and housing census.

2014.

Department of population ,Ministry of Labour, Immigration and

Population. Thematic report on Population Dynamics. Vol. 4. Office

No.48, Nay Pyi Taw, Myanmar; 2016.

Ko-Ko-Zaw, Tint-Swe-Latt, Phyu-Phyu-Aung, Thein-Gi-Thwin, Tin-

Khine-Myint. Prevalence of Hypertension and Its Associated

Factors in the Adult Population in Yangon Division. 2011.

Knodel J, Teerawichitchainan B. Aging in Myanmar. Gerontologist.

2017;(January).

31

References Ministry of Health and Sports. National strategic plan for prevention

and control of NCDs(2017-2021). 2017.

Myint-Han. Health care of the elderly in Myanmar. 2012;16(1):23–8.

Rajan, Sreerupa. Study on accessing health care by older population in

Myanmar. 2017.

Soe-Moe, Kyi-Tha, Khin-Saw-Naing, Maung-Maung-Than-Htike.

Health Seeking Behaviour of Elderly in Myanmar. Int J

Collaboration Res Intern Med &Public Heal. 2012;4(8):1538–44.

Than-Htike-Aung. Common health problems and treatment seeking

behaviors of elderly in Mandalay Division. 2012.

WHO. Accessing national capacity for the prevention and control of

noncommunicable diseases: report of the 2013 global survey.

Geneva; 2014.

WHO. Noncommunicable diseases [Internet]. 2017. Available from:

www.who.int/news-room/fact-s 32

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Age is only a number.

Keep an

active life

Thank you!