Poor health is a severe problem in Bangladesh, which is more visible in case
of women and children health. In-spite of the success of Expanded Programmes
on Immunization (EPI) and increased use of Oral Rehydration Therapy (ORT), the
under 5 mortality rate is still high (116/1000 live birth) (WHO,
1999). Pneumonia and diarrhea are the most common causes of death with malnutrition
increasing the death of children under five years of age. The Bangladesh Demographic
and Health Survey (BDHS) reported that children in rural areas of Bangladesh
experience a 36% higher risk of dying before age five than urban children (131
vs. 96 per 1000 birth, respectively). The infant mortality rate is 79/1000 5
birth (WHO, 1999). Where, 91/1000 live birth in rural
areas infant mortality rate and 73 in urban areas (BDHS,
1997). Every year some 12 million children die before the age of five. Seventy
percent of there deaths are caused by 5 common preventable or easily treatable
childhood diseases: pneumonia, diarrhea, measles, malaria and poor nutrition.
In Bangladesh, Acute Respiratory Infection (ARI) is the number one killer disease.
It represents a high burden for the health system and is a common reason for
consultation and admission to health facilities. Annual report of the national
ARI programme noted that ARI represented 15 to 20% of cases reported from Thana
Health Complexes (THCs) and district hospitals in 1995 (DGHS,
1997). Every year 148,000 children are dying due to ARI, mainly pneumonia
In Bangladesh 15% of the total population are children under 5 years of age
(UNICEF, 1999). In this regard, to improve the health
status of the population, especially child health, Government of Bangladesh
(GOB) made a number of efforts. For example, from July 1998 the GOB has taken
a major step towards reorganizing the health and population sector services,
which is known as the Health and Population Sector Programme (HPSP) (MOHFW,
1998). The HPSP, which aims to contribute to the improvement of the health
and family welfare status among the most vulnerable women, children and poor
in Bangladesh. It specially includes reduction of infant mortality and morbidity
for female and male children under five (MOHFW, 1998).
The health and population sector programme of the MOHFW (1998-2003)
documented that less than 40% of the population has access to basic health care
Child Health Care encompasses basic preventative and curative care for infants
and children. The GOB has implemented control programs for Acute Respiratory
Infection (ARI), Diarrhoeal Diseases, Vaccine-Preventable Diseases (EPI) and
prevention of vitamin A Deficiency disorders. While, there have been declines
in child mortality from all causes in Bangladesh, many children still do not
have access to preventive and curative services delivered by trained health
workers (Rahman, 2000; Mangoud et
al., 1997). Moreover, most sick children present with signs and symptoms
related to more than one of these conditions (MOHFW, 1998).
It is evident that the Infant Mortality Rate (IMR) and under 5 mortality rate
are still at unacceptable levels. The demand for child health care is high,
but the utilizations of the public sector facilities for child health services
are very low (Wouters, 1992; Begum,
1997). So, it is important to obtain information about the child health
care services provided through THC under the Essential Service Package (ESP)
to identify reasons for low utilization of those facilities.
During the last 15 years, Bangladesh has achieved significant reduction in
the child mortality rate. The Under 5 Mortality Rate (U5MR) in Bangladesh declined
from 151 per thousand live births in 1990 to 77 per thousand live births in
2001 compared to the United Nations (UN) goal of 70 per thousand live births
(WHO, 2003). Although, the last 2 decades have shown a
substantial decline in Bangladeshs child mortality rate, the levels are
still high by any standard (Pushkar and Pal, 2004). Considering
the poor health situation, the government of Bangladesh is committed to provide
health care services for all, giving special attention to the vast population
living in the rural areas (MOHFW, 2003). The NGOs and
international communities are also giving considerable effort along with the
government. In Bangladeshs health care system, NGOs play an important
role by providing healthcare at the grass root level and complementing the government
efforts through their countrywide network (Health Economics
Utilization of child healthcare services has been identified as an important
factor affecting child mortality (Govindasamy and Ramesh,
1997). The utilization of healthcare services is a complex behavioral phenomenon.
Empirical studies of preventive and curative services have often found that
the utilization of healthcare services is related to the availability, quality,
cost and comprehensiveness of services as well as socio-cultural structure,
health beliefs and personal characteristics of the users (Chakraborty
et al., 2003). Moreover, mothers education also has a great
impact on health and survival of children through curative means, whether the
mother uses modern facilities or traditional practices (Becker
et al., 1993). Nonetheless, child health has been considered as one
of the important indicators for describing mortality conditions, health progress
and indeed the overall social and economic well being of a country (Islam,
In this context, this study aims to investigate the issues involved in the utilization of health services. The focus is on child health care services, because child health care is one of the main components of Primary Health Care (PHC). A detailed understanding of the utilization pattern of THC services in rural areas of Bangladesh, particularly in child health care services, the factors affecting and recommendations for improving the situation will be intended to provide in this study.
MATERIALS AND METHODS
Selection of Area and Respondents
The Keraniganj Thana Health Complex was selected as the study area. It was
chosen to investigate the utilization pattern of CHC services in this particular
THC, which is located near the Dhaka City. The Keraniganj Thana is located in
the South-West part of the Dhaka District. It has an area of 167 km2.
The total population is 634158. Among them 20534 are 0-1 years old and 74511
are 1-5 years old. Administratively the Thana is divided into 12 unions and
36 wards. Under the Keraniganj Thana health complex there are 11 Family Welfare
Centers (FWC), 84 Satellite Clinics (SC) and 288 EPI outreach centers. Rate
of child immunization is 98.6%, vit. A coverage (0-5) is 95%. The growth rate
of population is 1.9%. There are 12 doctors in the THC, one Medical Officer
(MO) of Maternal and Child Health (MCH), 3 MOs of Family Planning (FP), 49 Health
Assistants (HAs), 3 Health Inspectors (HI) and 8 Assistant Health Inspectors
The study was conducted from April, 2006 to September, 2006 at the Keraniganj Thana Health Complex, Keraniganj, Dhaka, Bangladesh. The respondents consist of parents of the children under 5 years of age who were present in the THC. The parents were randomly selected among them who came to receive child health care service. The study was conducted among 50 parents. Among them 41 mothers, 5 fathers, 2 relatives and 2 father and mother together were included. Information about 64 children (29 boys and 35 girls) under 5 years of age were found from 50 respondents.
Variables and Sources of Data
Education level of mother, family income, knowledge and attitude of the
people about THC services and accessibility factors like distance, travel cost
and travel time were taken as independent variable. The CHC services provided
by the THC: EPI, diarrhea treatment and ARI treatment were taken as dependent
variable. Primary data was collected from the Keraniganj THC through the interview
of parents of under-5 children. The secondary data was collected from reports
of BBS, BDHS, DGHS, WHO and MOHFW.
Method of Data Collection
A questionnaire was set up to interview the users of CHC services at the
THC which focused on the socio-economic status, knowledge and attitude of the
people about CHC services at the THC, demographic factors and information about
the children under 5 years of age. Interviews were carried out among parents
of the children of under 5 years of age who were present in the THC during the
time of interview at the THC. They were randomly selected from parents as respondent
who came to receive child health care services for their children. Fifty parents
were interviewed for the study.
Methods of Analysis
The quantitative data have been presented in tabular form and analyzed by
using descriptive (Hootman, 1992; Gordon,
2008) and bivariate analysis (Levy and Nobay, 1986;
Reitsma et al., 2005). The objectives of these
analysis were to understand the distribution pattern of the study data in general;
identify the relationship between the dependent and independent variables and
finally to estimate the overall effects of independent variables on the use
of CHC services.
This analysis paints a picture of the quantitative data. It examines the
variability of data and describes the sample (Hootman, 1992;
Gordon, 2008). It also provides a description of the characteristics
of the study population including their socio-economic condition, health seeking
behavior and types of health service facility they use during sickness in general
and specifically at the time of CHC need. All this information was found to
be important and provides a good basis for further analysis.
To gain an understanding of the cross variation and association between
dependent and independent variables, bivariate analysis has been performed (Levy
and Nobay, 1986; Reitsma et al., 2005). Two
independent variables, family income and education level of mothers were selected
for this analysis. Three child health services, immunization, diarrhea and ARI
treatment were selected as dependent variables. Bivariate analyses were performed
using dependent and independent variables.
Results of Bivariate Analysis
Various bivariate analyses of dependent and independent variables were explored
to identify reasons for under-utilization. Two independent variables: education
level of mother and family income has been selected for this analysis. These
variables have been chosen based on the finding from studies in other countries
that reported their effect on the utilization of health services. The bivariate
analysis helped in understanding and in identifying factors those have significant
effect on the utilization of services. The bivariate analyses provided individual
effects of these 2 selected independent variables on the use of different CHC
services provided through the THC.
The results show that on average 96.23% of children received vaccination
at some time irrespective of level of family income. Similarly, 97.3% of children
received vaccination irrespective of the level of education of mothers. The
children from medium income group received more vaccine (95.83%) than that of
low income group (92.86%). All children (100%) from high income group are vaccinated.
A similar trend was also found among the 3 education groups. All the children
(100%) of primary and above primary educated mothers received vaccination in
the sample population. The result show that only 4% of all study children did
not received vaccine ever. They are mainly from low and medium income families
and non-educated mothers families. These findings are shown in Table
1 and 2. The vaccination is found to be higher in high
income and primary and above primary educational group compared to that of low
income and uneducated groups. These findings indicate that the family income
and mothers education has some individual effects on the vaccination in
the Keraniganj area, which is similar in case of rural areas of Bangladesh (Bhuiya
et al., 1995; Biswas et al., 2001).
Child Vaccination at THC
The highest number (33.33%) of child vaccination received from THC was found
in the middle income family groups and lowest number (14.29%) in the low income
family groups. Similarly, this number is highest (40%) in the primary educated
mothers group. Then gradually above primary educated (37.50%) and non-educated
(24%) mothers children received vaccination from the THC. So, it is clear
that the trend of receiving EPI service from the THC and is affected by both
education of mother and family income as shown in Table 3
and 4. The utilization of 3 basic child health care facilities
significantly higher in the case of educated mother as well as medium and high
||Distribution of child vaccinated among three income groups
||Distribution of child vaccinated among three education level
||Distribution of three CHC services taken from THC according
to the level of mother education
||Distribution of three CHC services taken from THC according
to the income level
||Incidence of diarrhea and ARI among three income groups
||Incidence of diarrhea and ARI among education level of mothers
So, a significant association was found between the family income and mothers
education and vaccination at THC. The higher the level of income and education,
the higher the rate of utilization of the EPI service. The reason may be that
educated mothers and parents of higher income families are more concerned about
immunizing their children and they come to the THC by themselves. On the other
hands, less educated mothers and lower income family members are mostly inspired
to immunize their children by the health worker or others. As a result they
go to the nearest service centers.
Incidence of Diarrhea
The overall incidence of diarrhea among the children of the study sample,
within the 2 weeks before the study was almost 30% (19 cases among 64 children
found from 50 respondents). The incidence of diarrhea was more (42.9%) among
lower income group. Then among medium income group (41.7%) and high income group
(27.3%). It was more (87.5%) in the group of above primary mothers family
and less (30%) in the primary educated mothers family. The incidence of
diarrhea significantly association with the income level of the family as shown
in the Table 5. Only 27% incidence was observed in high income
group compare to that of low (43%) and medium (42%) (Table 5).
Therefore, the lower the income, the higher the incidence rate. Whereas the
high incidence was observed in family with above primary educated mothers (88%)
Incidence of ARI
The incidence of ARI among the children of the study has found to be 55%
(35 cases among 64 children found from 50 respondents). The incidence of ARI
was found more among the children of higher income group (81.9%) compared to
middle (70.9%) income group and low (42.9%) income group (Table
5). But children from the primary educated mothers families had higher
(90%) incidence of ARI compared to that of above primary (75%) and non educated
(72%) mothers family (Table 5). So, a positive relation
was found between family income level and incidence of ARI.
The Place of Diarrhea Treatment
Out of 19 children with diarrhea, 15 (79%) were treated in the THC. More
children from middle income group (33.33%) (Table 4) and from
above primary educated mothers family (62.50%) (Table 3)
visited THC for diarrhea treatment. Then gradually other income groups, low
income and higher income groups came to THC for diarrhea treatment. So, there
is no significant association found between income and diarrhea treatment received
from THC. But a clear association between educated mothers family and
diarrhea treatment at THC was found from Table 3. We see that
the incidence of diarrhea and treatment reception is higher in the cases of
children from above primary educated mothers family (62.50%).
The Place of ARI Treatment
Out of 35 children with ARI, 33 (94.2%) were treated in the THC. More children
of non-educated mothers family (84%) and from lower income families (71.43%)
visited THC for ARI treatment. From Table 3 and 4,
we can see the above findings and also that there is no clear association between
education of mothers and ARI treatment reception at the THC. But lower income
families receive more ARI treatment from the THC than higher income families.
The reason may be free supply of medicine from the THC.
Cross Table Analysis
Table 7-9 reflect that non-educated
mothers are higher (71.43%) in the low-income family groups than middle-income
(55.56%) and higher income (50%) family groups. And there is no above primary
educated mothers (0%) in the low income family group which is highest (50%)
in the higher income family group.
Children from middle income families and from primary educated mothers families receive more EPI service from the THC compared to other groups. Similarly, frequencies of ARI and diarrhea treatment reception are higher in the lower level of income and education groups. So the findings from above tables support the results of previous analysis.
Knowledge, Attitude and Use of CHC Services
From the following tables, Table 10 and 11,
we can see a picture that the percentage of awareness about child vaccination
is higher in the families with higher education (90 and 75%) and also higher
income (100%). It is clearly evident from the above tables that educated mothers
are more concerned about child vaccination. The similar trend is seen in case
of higher income family groups. Percentage of self decision of mother is higher
(62.5%) in the above primary educated mothers than other groups such as no education
(40%) and primary education (60%) (Table 12).
||Association between level of education and use of three CHC
services for respondents of low income group
||Association between level of education and use of three CHC
services for respondents of medium income group
||Association between level of education and use of three CHC
services for respondents of high income group
||Association between education level of mothers with their
awareness about child immunization
||Association between level of income and awareness of mothers
about child vaccination
||Association between decision making with education level of
||Association between decision making with income level
||Association between distance and use of three CHC services
On the other hand, the mothers decision making is higher in the medium income family groups (61.11%). Decision taken by other than mother and father is higher (100 and 66.67%) in the non-educated and lower income category and zero in the primary level and middle income family group (Table 13). Mothers decision making is increasing with the level of education. On the other hand, fathers decision making is negatively related with income and mothers education. In the medium income families, mothers also earn by doing some job. So, they can contribute in decision making.
Access and Use of CHC Services
The results of bivariate analysis of Table 14 shows that
distance was significantly associated with the use of THC for EPI service. It
was found that those who live within 3 miles from the THC used more EPI service.
Diarrhea treatment and ARI treatment are not clearly related to distance.
||Association between travel cost per visit and use of three
||Association between travel time and use of three CHC services
In case of travel cost as shown in Table 15, percentage of user declined with the increase of that cost. So, it was found that travel cost is a significant factor for the use of CHC facility at THC. If we consider the association between travel-time and use of CHC services, we see that the frequency of the use of EPI services and diarrhea treatment declines with the increase of travel time (Table 16). The lower the travel time, the higher the percentage of service use in each of the cases of EPI and diarrhea. But no clear association was found between these variable and ARI treatment at THC. So, the level of utilization of EPI service at the THC is negatively related with the travel cost, distance and travel time.
Bangladesh is one of the least developed countries in the world and per capita
income is US$ 273 (BBS, 1998 and BBS
and UNICEF, 1998). The majority (84.36%) of the countrys population
lives in the rural areas (BBS, 1996, 1997).
Socio-economically it is less advanced and is a traditional rural society. Use
of modern health services of this major section of the population depends partly
on their socio-economic condition. Studies in different country have also found
association between the socio-economic conditions such as education and family
income on the use of health services. The third and fourth 5 years plan (1980-90)
of the government of Bangladesh took an integrating view of national development
in a long-term perspective to address the acute problem of poverty, unemployment,
rapid population growth, malnutrition and illiteracy. The process is continuing
to improve the socio-economic conditions of the people, but it is far away from
achieving the targets (Rahman, 2000; Mangoud
et al., 1997).
It was found that majority (72%) of the study population use THC for all kind of treatment for their children and rest of them use other available sources of health service. But to ensure 100% use of the THC or at least to increase the use THC, the government should concentrate on improving the quality of service provided by the THC. Almost, 50% of the respondents reported good quality of service but the percentage of moderate and bad repot are not very low. The main reason for not using THC was found to be non-availability and in particular ineffectiveness of medicine for the children.
Family income and mothers education was found to have positive individual effect on the rate of child vaccination. The percentage of vaccinated children (97% approx.) among the sample population was found close to that of the recorded percentage (98.6%) at the Keraniganj. It was found in the study that higher level of knowledge of the respondents about the CHC service provision of the THC increases the use of THC. Mothers education and family income had clear association with the use of THC in particular EPI services. Mothers education was found to be significantly associated with the reception of diarrhea treatment at the THC but not with that of ARI treatment at the THC. No significant association was found between income and diarrhea treatment reception. But the rate of ARI treatment at the THC was found to be higher in the lower income families. Knowledge and attitude about the CHC services at the THC was found to be positively related with family income and education of mothers. Evident was found that educated mothers are more concerned about the health status of their children and receiving treatment. A similar relation was also found in the cases of higher family income groups. The decision making capacity of the mothers was positively related with the level of education of mother and higher family income. On average, reception of ARI treatment at THC is higher (94.2%) compared to that of diarrhea treatment (79%) and EPI (29%), irrespective of the income group and mothers education.
It was hypothesized that difficulties in access to the THC were deterring people
from using CHC in rural Bangladesh. The findings show significant association
between distance and use of THC. This was more dominant in the case of EPI service
reception but not very much in case of diarrhea and ARI treatment. Travel cost
was found to be a significant factor for the use of EPI and diarrhea treatment
but not for that of ARI treatment. Travel time had negative relation with the
use of EPI services and diarrhea treatment but it had no clear effect on the
use of ARI treatment. The reason may be, in case of emergency, people do not
care about distance, time or cost but seek for proper treatment. Primary health
care won widespread acceptance, among both governments, international and non-governmental
organization since 1978. Different countries restructured their health system
based on the primary health care concept (DGHS, 1997).
A wide range of basic services has been organized at the grass root level for
improvement of the health status of the population particularly maternal and
child health. However, as we see in this study the utilization of those services
is still low in Bangladesh like other developing countries. Available studies
show that utilization of health services is influenced by individual, communities
as well as health care delivery system of the country (Rahman,
2000). Utilization of health care services is affected by various factors.
The circumstances and characteristics of the client are designated as user factors
such as age, sex, education, income, parity, culture and attitudinal factors.
On the other hand, variables primarily associated with service delivery systems
or facilities are designated as service factors such as availability, accessibility
of services and quality of care (Rahman, 2000).
We observed that educational status, income, knowledge about immunization and
communicable diseases, etc play an important role in influencing the people
toward immunization as well as utilization of health care services. The results
were related with the observation as mentioned by Begum
(1997). It is revealed by them that the major causes for non-awareness about
EPI diseases and vaccines were ignorance and negligence, bad communication and
side effects after vaccination.
It was found that the reasons for under-utilization of health care services
range from individual behaviour, community characteristics as well as health
system of the country. The pattern of utilization is not molded by one to one
relationships of variables. It is a complex relationship among those variables
that decide the utilization of health services (Rahman, 2000).
The accessibility, as well as the quality of the services, shortage of medicine
and long waiting time at public provisions is also responsible for such behaviour.
Long distances as well as long waiting time for treatment are noticeable in
rural areas (BBS, 2001).
These findings of the study substantiate the facts that socio-economic status
exerts a dominating control on child healthcare in Bangladesh. Although, mothers
education plays a dominating role in their childrens health status, poverty
status plays a more vital role in the selection of qualified providers (Huq
and Tasnim, 2008). Therefore, we believe that parents education level
and socioeconomic conditions can substantially improve the utilization of child
primacy health care services at THC in Bangladesh.
Findings proved that quality of public sector health care facilities is unacceptable to people, as such; priority of the government needs to be shifted from expansion of facilities to improvement in the quality of services. A comprehensive training program on behavioral change could be initiated. Supply of sufficient amount of drugs is necessary in the THC. Emphasis should be given on the local need and especially on the treatment facility of endemic diseases.
The main limitation of this study was the small sample size. A larger sample
size could help to get clear idea about the relationship among the variables
that were hypothesized to be affective for the use of CHC services at the THC.
The study was conducted only on one THC, which was not sufficient enough to
draw any concrete conclusion from the information collected. Information was
collected from the users perspective but providers perspective had
to be considered also. Respondents were selected among those who were present
at the THC for receiving CHC services. So there may have some probability of
recall bias in case of informing about the quality of services.
Suggestion for Further Research
The information should be collected both from users and providers
perspective to get more distinct and significant association between the variables.
A larger sample size would help to draw conclusions about the relationship between
the variables. Sample from more than one THC should be taken for more accurate
results. A further research on the utilization of CHC may be carried out on
other health care facilities in public and private sectors. A comparison on
utilization of CHC services between private and public facilities can be made.
The authors are indebted to Dr. A.M. Muzaffaruddin Ahmed, Upazila (Thana) Health and Family Planning Officer, Keraniganj for providing all supports to collect data from the THC.