Associations of socioeconomic determinants with community clinic awareness and visitation among women: evidence from Bangladesh Demographic and Health Survey-2011

Low prevalence of awareness and visitation of CCs were identified in the current study
among women in Bangladesh which is congruent with the findings of studies on care
seeking behaviors and healthcare avoidance that were conducted in the USA 20], 21], Nepal 22] and Nigeria 23]. In the USA, one study 21] reported that only around 21 % of the sampled population visited the emergency department
at least once. On the other hand, another study 20] described that about 34 % of the respondents avoided seeing healthcare providers
when something wrong was suspected with their health. In Nepal, it was reported in
a study that approximately 89 % of women did not seek treatment for their ill children
22], whereas in Nigeria 23], this rate was much higher (93 %). In India only 12.7 % mothers reportedly registered
their name at PHC centers 24]. There may be various reasons behind this high prevalence rate of untreated sick
children in developing countries; however, lack of easy access to healthcare facilities
as well as lack of basic health education system could be major barriers to ensuring
primary healthcare for vulnerable people, including children. As the CCs provide easy
access for patients because of their convenient location, as well as one of their
primary functions being basic health education, CCs could easily play vital roles
in ensuring primary healthcare in their respective localities. The establishment cost
burden of a CC for the respective government is minimized by sharing the cost with
the local community under PPP style agreements, facilitating the quick spread of CCs
even in a less developed country like Bangladesh. Such evidence is important for other
countries, especially for developing countries, where many people still have limited
access to primary healthcare facilities.

Noted low prevalence of awareness as well as of low CC visitation among participants
of the current study may indicate lesser efficacy of CCs in Bangladesh. However, it
is too early to conclude about efficacy of CCs in Bangladesh because alternative forms
of similar services, specifically for women, also exist, such as door-to-door health
and family planning services provided by different field level health workers (Health
Assistants, Family Welfare Assistants). Primary level health care is also provided
from the Union Sub-centers and Upzilla Health Complexes. However, as these centers
are not located in each community, not all people have easy access to these centers.
CCs on the other hand are very convenient by their location, although other facilities
at CCs should be improved to accomplish the goals of their establishment. However,
it could be relevant to compare with those of USA, Nepal and Nigeria in the sense
that future progress of awareness and visitations could be solely attributed to the
impact of CCs, considering current rates as baseline information.

The low rate of health awareness and treatment-seeking behavior in this country could
be due to a lack of knowledge about the causation and characteristics of illness,
stigma, and lack of privacy. Cultural and religious views may also be striking factors
behind such behavior in Bangladesh. In addition, attitudes toward health awareness
and treatment-seeking behavior are highly dependent on the degree of motivation to
seek appropriate health care. Most people in Bangladesh have fairly low expectations
of public health services 9] and largely rely on private services 25]. To improve access to PHC, it is necessary to involve community leaders more actively
in health intervention programs that focus on improving attitudes towards health and
health care, improve patient service-providers relationships, and the implementation
of special beneficiary packages like a voucher scheme for pregnant women 26], 27].

Reports are available to demonstrate the association between age and utilization of
medical services. The results of our study indicated that older women were more likely
to seek treatment from CCs than younger women (?19 years). Similar findings were identified
among mothers seeking treatment from doctors, nurses, and midwives for delivery complications
in Bangladesh 4]. The reason behind this could be the leading position of older mothers at family
setting and they have more decision-making power. In addition, older women may be
able to gather more information regarding health services, which may have a positive
impact on utilization 4]. Since most of the women in Bangladesh bear their children between 20 and 39 years
of age, they are naturally more conscious about sickness related to children’s health.
As a result, when their children become sick, they utilize the maximum level of available
health care services from nearby health facilities. The opposite kind of findings
are seen in a study conducted in Nigeria which described younger mothers with better
care seeking behaviors than older mothers 23]. This might be due to a cultural issue, wherein young women in Bangladesh might have
less decision taking power in their families 28].

Women having primary education were more likely to have awareness and seek treatment
from CCs than those who did not go to school. Similar findings were observed in several
published studies of various kinds of health care utilization 4], 5], 29]–34]. Educated women probably had better access to health information and thus were able
to utilize such information optimally. Similarly, they are better equipped for initiating
and controlling decision-making affairs regarding health issues 35]. Education is considered one of most dominant socioeconomic determinants of health
and health related behaviors. It reflects socio-cultural characteristics of individuals
as well 36]. In addition, highly educated mothers are known to be better users of health information
and services 37] and are thus expected to have better healthcare seeking behaviors for their ill children.
Community groups should be used as a platform to provide health education in addition
to using mass media for utmost utilization of PHC.

Participants residing in rural areas were more likely to have awareness compared to
their urban counterparts at CC setting. This could be due to better accessibility
to CCs among rural women in Bangladesh. CCs are located very near to residential areas,
as they are established with the aim to improve the accessibility of PHC, particularly
among women and children.

Women who had less than two children they were more likely to have awareness than
those who had two or more children, similar to the finding of a study conducted in
Nigeria 23]. This might be due to a huge effort by the family planning department having a positive
effect on the one or two children strategy in Bangladesh.

Women living with lower wealth index were more likely to have awareness about CCs
and they visited CCs more than women of higher wealth index. The reason behind this
could be due to limited health services available in CC. There is no certified medical
doctor appointed for providing health services in the facility. Only para-medical
or trained health care providers provide PHC services in the CCs. Perhaps as the women
of higher wealth index had scope to visit graduate medical doctors and more equipped
medical centers, they did not visit CCs much.

The strength of the present study is that it used the data from a nationwide demographic
and health survey, and then used the cluster sampling method to make our study general
population representative. However, several limitations of the current study should
be considered. Firstly, we included only female respondents; factors among males may
have been different. Secondly, our study design was cross-sectional, which cannot
establish a cause and effect relationship. Further cohort studies are needed to establish
this relationship. Thirdly, certain missing population groups, such as homeless women,
and lack of social and cultural influence may affect heath care seeking behavior from
CCs. In addition, our study was conducted only 2 years after the restart of CCs following
a long 8-year nonfunctioning period. The prevalence of awareness about CCs and treatment-seeking
behavior at CCs might have changed over time. Despite these limitations, we believe
that the present findings are important; this was a preliminary study carried out
among women aged 12–49 years in Bangladesh, evaluating the associations of socioeconomic
determinants with awareness and visitation and is, to our knowledge, the first study
addressing the influence of socio-economic determinants on CCs in Bangladesh using
nationally representative data.