Data were collected from the villagers through a survey. Informed consent was taken verbally from the respondents and they had complete right to withdraw from providing information at any point of the interview. The study was reviewed by the Ethical Review Committee of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B) which follows the international standard for research ethics. Detailed methodology of the study is presented below.
Study area and study period
The present study was carried out in Chakaria, a remote rural area in Bangladesh. Administratively, it is under Cox's Bazar district. The population density is 782 individuals per square kilometre. The highway from Chittagong to Cox's Bazar passes through Chakaria. The east side of Chakaria is hilly, while on the west side towards the Bay of Bengal, is lowland.
The health and other development indicators of the area lag behind those for the rest of the country. The total fertility rate in Chakaria during 2007 was 3.5. The infant and under-five mortality rates during 2007 were 48.0 and 63.4 respectively. Life expectancy at birth was 67.2 years for males and 69.7 years for females in 2007 . However, the challenges facing the health systems of the area are common to those facing the rest of rural Bangladesh and therefore the conclusions derived from this area can be generalized for the rest of the country.
The survey was carried out during February 2007.
Data presented in this paper come from eight of the 18 Unions of Chakaria Upazila (sub-district). A Health and Demographic Surveillance Systems (HDSS), known as the Chakaria HDSS, runs in these eight unions which gives information on the demographic, socioeconomic and other health indicators of the area on a quarterly basis. Chakaria is an INDEPTH member site . It collects data from 7,600 systematically randomly-chosen households out of 26,979 households of the eight unions of Chakaria.
The current survey was carried out among 1,000 households randomly selected from the 7,600 households of Chakaria HDSS. Information on illness prevalence was collected from a total of 6,162 members who were living in these 1,000 households at the time of data collection.
From these selected households 892 households had at least one member who was sick during the 14 days preceding data collection. For the households that had more than one sick member, one was selected randomly for data on health seeking pattern. Among these 892 household members, 120 were not available at the time of data collection, 2 refused to participate in the survey and there were missing information on another 5 members. Therefore, information on health seeking pattern was collected from 765 household members who were sick during the 14 days preceding the survey.
A structured questionnaire was developed in Bangla to collect information on health-seeking behaviour of the villagers. The questionnaire was administered on villagers who have been sick during the 14 days preceding the survey. This questionnaire was pre-tested outside the study area in order to ensure consistency, appropriateness of language and sequencing of the questions. Based on the feedback from pre-testing, the questionnaire was modified and rephrased where necessary. Data were collected on: type and symptoms of illnesses, care-seeking behaviour during illness including home remedy and consultation with healthcare providers, type of health care provider contacted, and the socioeconomic characteristics of the households. Information on type and symptoms of illness were collected through open-ended questions.
Respondents were the adult sick persons themselves. For the sick children the respondent was either their mother or their caregiver. In total, health-seeking behaviour was recorded for 765 individuals.
Among the sick household members 36% were male and 64% were female and their mean age was 26 years varying from newborn to 93 years of age. Majority of these household members (51%) aged over five years were illiterate, 29.5% had one to five years of education and 19.5% had six or more years of education with the maximum not exceeding 14 years of education.
21 interviewers with 12 years or more of formal education were recruited for data collection, majority of whom had previous field experience. Two supervisors supervised the interviewers in two groups. Interviewers received in-class training for 3 days and had field practice for another 2 days followed by a long de-briefing by the supervisors at the end of each day. An instruction manual explaining the key terms in the questionnaire was developed and provided to the interviewers as a guide.
Data management and analysis
Each questionnaire was scrutinized in the field and at the field office on the same day of the interview. The supervisors besides the day-to-day supervision, re-interviewed 3% of the households and any inconsistencies identified between the two interviews were corrected. Inconsistencies identified while checking the questionnaires were sorted out through additional field visits, if needed, by the supervisors. Data entry using Foxpro database software started within two days of the start of data collection.
Data analysis was carried out using SPSS. Cross tabular analysis was carried out. Chi-square test has been used to test the statistical significance of relationships.
The socioeconomic status used to analyse the data was derived using asset index. The list of assets is similar to the one that is in use at the Chakaria HDSS which included Van/rickshaw, bicycle, motorcycle, television, telephone/cell phone, radio, watch/clock, couch, chair, table, bed (khat/chouki), mosquito net, quilt/blanket, electricity connection, sewing machine, tube well, sanitary latrine, mattress, and Almira (closet/cabinet) . All these assets were coded as dichotomous variables where ownership of an asset was coded as 1 or 0 otherwise. Each household asset for which information was collected was assigned a weight equal to the factor score generated through a principal components analysis. We followed the SPSS factor analysis procedure. Individuals were then ranked according to the total score of the households they belong to [6–8]. Finally using these scores the sample was stratified in five quintiles from lowest to the highest quintile; the higher the quintiles, the better-off the households.
Health-seeking behaviour has been defined as a "sequence of remedial actions that individuals undertake to rectify perceived ill-health"[9–11].
The illnesses mentioned in this report are based on reported symptoms or names of illness reported by the respondents themselves. In case of mentioning a name of an illness symptoms were also recorded. For ease of analysis, diseases of similar type were grouped together based on the coding scheme developed by a physician. The broad categories in which diseases were grouped together were: respiratory tract diseases, infectious diseases, neurological diseases, gastro-intestinal tract diseases, skin and soft tissue diseases, musculo-skeletal diseases, kidney and urinary tract diseases, eye problem, cardiovascular diseases, cancer, cold/fever, diarrhoeal diseases, and hepatobilliary. If a single patient mentioned multiple illnesses within the reporting time period, they were recorded. However, for our current analysis health-seeking behaviour for that particular patient was recorded for the most recent illness.
Any remedial action undertaken by an individual without consulting a healthcare provider has been considered as 'home remedy'.
For the current analysis Village Doctors were defined as informal healthcare providers and or drug vendors practicing allopathic medicine. Village Doctors practicing homeopath or other traditional medicines were not included in the analysis.
In 2007, a survey was carried out to investigate the characteristics of Village Doctors practicing allopathic medicine in Chakaria. It was found that of the total 328 Village Doctors practicing allopathic medicine 95% were male and the mean age of Village Doctors was 39 years. All the Village Doctors had passed at least 7th grade of education. However, only 4% had government accredited training in the system of medicine that they were practicing whereas others had non-accredited trainings of various durations. Village Doctors had embarked on the profession by attending courses or trainings, by being a trainee in a drug store, assistant in a doctor's chamber or of a Village Doctor or by inheriting the livelihood from a family member. One important fact was that majority (82%) of the Village Doctors in Chakaria sell drugs alongside their practice .
The socioeconomic status of the individuals was derived by using the asset quintile approach and the individuals were grouped into five quintiles: lowest quintile (poor), second quintile, third quintile, fourth quintile and the highest quintile (better-off).