Health Seeking Behavioural Practices of the Elderly in Rural Community of Ekiti State, South-western Nigeria

The ageing process increases the risks of contracting a disease among elderly people. Health-seeking behaviour is poor among the aged in sub-Saharan countries like Nigeria, escalating the burden of Non-communicable diseases and the cost of healthcare which further impact the utilization of Orthodox medicine. This study aims to assess the healthcare-seeking behavioural practices and associated factors among elderly people in Ido-Ekiti. Method A descriptive cross-sectional study was conducted amongst 420 elderly respondents in Ido-Ekiti. An interviewer-administered semi-structured questionnaire was used to collect information. The data collected were analyzed using SPSS version 25 and results were presented in form of tables and bar charts. Chi-square tests were used to test for associations. All data analysis was done at a 5% level of signicance.


Introduction
An elderly person according to the World Health Organization is an individual who is 65 years and above and this de nition is adopted by most developing countries [1]. United Nations agreed cut-off is 60 years and above for an elderly person [2]. In Nigeria, those aged 65 years and above make up 3.1% or 5.9 million of the total population of 191million [3,4].As medical advances allow people to live longer, the proportion of the elderly will increase in Nigeria [5]. Ageing causes people to be less active, frail and exposed to more risk of contracting diseases.
The elderly, being considered the most vulnerable group of individuals, face a myriad of problems varying from medical problems to psychological and social problems. The Elderly are more predisposed to developing.Cardiovascular diseases, Respiratory diseases, Gastrointestinal diseases, Mental illnesses amongst many other medical problems. In addition, other problems of the elderly include poverty, unemployment, abuse, stigmatization, isolation, and depression amongst others.
Health-seeking behaviour is de ned as a sequence of remedial actions that individuals undertake to rectify perceived ill-health. Today, it has become a tool for understanding how people engaged with the health care systems in their respective socio-cultural, economic, and demographic circumstances [6].
Majority of the aged persons have associated illnesses such as hypertension, diabetes, joint pains/arthritis, kidney infections, cancers, Tuberculosis that take a long time to treat which particularly affect their health-seeking behaviour. Elderly individuals are found to have patronized traditional healers, consult Christian/Islamic clerics, resorted to self-medication using local herbs, or visit chemist shops whenever they are sick instead of seeking orthodox care [7].
A study revealed that more than two-thirds (68.8%) of respondents had never visited health facilities In the last year even for medical checkups [8]. Some of the reasons for not patronizing orthodox health facilities include the cost of orthodox health care services, cultural belief, availability, a distance of the health facilities amongst others. Several studies have also documented an association between certain socio-demographic and socio-economic variables and healthcare-seeking behavioural practices.
This study aims to determine the healthcare-seeking behavioural practices among the elderly in rural settings of Ekiti state Nigeria and to identify factors that in uence the practices. This study will provide information that will assist the policymakers to formulate policies that will reduce morbidity and mortality associated with old age. Limited study on this has been carried out in the study area on the healthseeking behavioral practices among the elderly Methodology Materials and Methods

Study Area
This study was conducted in Ido-Ekiti town in Ido-Osi local government situated in the northern part of Ekiti state, Southwest Nigeria. It is bounded in the east by Ipere and Iludun, in the south by Igbole and I nsin axis, and in the north and northwest by Usi and Ilogbo Ekiti [9,10] Ido-Ekiti town consists of two wards; Ido 1 and Ido 2 which are subdivided into twenty-two (22) settlements. There are three health facilities in Ido-Ekiti; A Basic Health Center, a Comprehensive Health Center, and Federal Teaching Hospital Ido-Ekiti [23][24]. Yoruba is the predominant tribe and Christianity is the predominant religion practiced. The population of people in the Ido-Osi local government area according to the 2006 census is 160,001and the population of the elderly is 6,060[9,10].

Study Population
The study is a cross-sectional study design that assessed the health care seeking behavioural practices amongst the elderly in Ido-Ekiti. The study populations were all elderly persons aged 65 and above in Ido-Ekiti, Ekiti State Nigeria. The study included elderly of both sexes 65years and above, who were willing to participate in the study. However, Elders 65years and above who were not willing to participate were excluded.

Sample Size and Sampling Technique
The sample size was calculated using Fisher's formula for estimating the minimum sample size for descriptive studies using the proportion of older people above 50years who consulted a health practitioner (53%) [11], with P-value set at ≤ 0.05 and con dence interval of 95% and a non-response rate of 10%. The nal estimated sample size was 420.
A multistage sampling technique was used to recruit the eligible participants. In Stage 1: Ido ward 2 was selected by simple random sampling technique out of the two wards in Ido-Ekiti. In Stage 2: four settlements, Oke-Isoko, Ijemu, Alapo, Isolo were selected by simple random sampling. In Stage 3: A Street was selected in each of the settlements by simple random sampling using all the streets in the settlement as the sampling frame. And in Stage 4: The houses along the street selected in stage 3 were numbered and simple random sampling was employed to select the houses to visit. Equal allocation was used to determine the number of participants in each street, and the required respondents were selected by simple random sampling technique using balloting.

Data Collection
Six data collectors and one supervisor were involved during the data collection process. A pre-tested, interviewer-administered, standardized semi-structured interviewer-administered questionnaire was developed and used to obtain information from participants. The questionnaire had 4 sections that addressed the socio-demographic characteristics, level of awareness of illnesses, the pattern of health care seeking behavioural practices, factors affecting healthcare-seeking behaviour of participants. Data collection was subject to strict controls and procedures which were followed precisely, to ensure that the data was valid, reliable, and useful.

Data Management
Data collected was checked for completeness, edited, coded, and entered into SPSS 25 statistical software for analysis. Descriptive statistics were presented as frequency distribution, means, and percentages. Chi-square and Fisher exact were used to determine the association between socio-demographic variables and Healthcare seeking behaviours and factors associated with healthcareseeking behaviour. Results were interpreted and a conclusion was drawn using a P-value set at 0.05.

Ethical Approval
Institutional Ethical approval was obtained from Federal Teaching Hospital Ido Ethical Committee. Permission to conduct the study was also sought from the Ido community leaders and verbal and written consent was obtained from the participant before the study was conducted.

Result
The result of the study shows a response rate of 100 percent. The age of elderlies ranged between 65 -95 years with a mean age of 73.88 ± 6.84 years ( Table 1). More than half of the respondents (64.0%) were within the age range 65 -75 years with Females constituting 61.0%. The majority of respondents were Christians (80.0%) and 97.1% of them were of the Yoruba tribe. More than half (60.5%) of the respondents were married and 37.9% widowed. The majority (87.4%) of the elderlies were unemployed and about half (52.4%) of them had no formal education. The majority (61.7%) had their source of income from work/trades and 32.1% of them were from family. Most of the respondents (82.6%) do not live alone, with the majority living with their spouse (66.9%) and one-quarter (25.4%) living with children. And about half (50.7%) of the respondents are taken care of by their spouses and 44.0% by their children (Table 2).
Figure1 is a bar chart that shows Majority of the respondents in the study have poor health-seeking behavioural practices 172(64.7%) while 94(35.3%) have good health-seeking behavioural practices.
Respondents that were considered to have poor health-seeking behavioural practices in this study were those that either self-medicated, did nothing, pray and seek for supernatural healing, visited patent medicine store while those respondents that consulted a doctor in either a public or private health care facility were considered to have good health-seeking behaviour In table 4, two-third (68.0%) of respondents who utilized Orthodox health care, visited a public health facility, whereas 29.8% visited a private facility. Less than half (46.8%) of them were satis ed with services rendered, on the other hand, 53.2% of them were dissatis ed. The majority (90%) of respondents who were dissatis ed with the services reported length of time for consultation, the attitude of health workers, unavailability of a physician, poorly organized hospital services, and high cost of services as reasons for dissatisfaction. About 48.9% of those who had visited healthcare facilities for health challenges indicated not being willing to patronize the hospital again when sick. For respondents that fell sick more than once in the last year preceding the study, the last episode was taken as a reference point in the study to minimize recall bias.   ,and lack of support from relations(73.8%).Con dentiality issues and beliefs of respondents least affected their seeking Orthodox health practitioner care. Table 6 and table 7 show the Association between socio-demographic variables and health-seeking behavioral practices among the respondents who fell sick within the last year preceding the study. Only employment status and levels of education were statistically associated with health-seeking behavioural practices. About 61.3% of employed elderlies had good health-seeking behaviour as compared to the unemployed (32.5%) and the retired (0%). Furthermore, 84.6% of those with tertiary education as their highest level of education had good health-seeking behavioural practices as compared with those with no formal education (29.1%), primary education (35.9%), and secondary education (44.4%).
The following factors are statistically signi cant to the health care seeking behavioural practices among the respondents namely the cost of healthcare, accessibility of health facility, beliefs of respondents, length of time before consultation, con dentiality issues, and lack of support from relations, with their p values of less than 0.001 as shown in table 8. Respondent's knowledge of the disease was not signi cantly associated with their health-seeking behavioural practices (p-value of 0.190).

Discussion
This study sought to assess the healthcare-seeking behavior of elderly people and determine the associated factors and predictors of their health-seeking behaviors'. Out of 420 respondents, 266 respondents reported falling sick in the last year. The majority of the respondents that fell sick in the last year had (64.7%) had poor Health care-seeking behavioural practices and about one-third (35.3%) had good health-seeking behavioral practices. These ndings were similar to a survey conducted in Ilorin, Nigeria in which the majority of the sick elderly people engaged in self-medication in the past year [8].
Another study in a rural community in Nigeria showed most elderly sought healthcare services from patent medicine stores which indicate poor health-seeking behavioural practices [12]. This is most probably due to the high cost of seeking orthodox healthcare as seen in this study where the majority of the respondents that perceived the high cost of orthodox care services as a barrier to seeking orthodox care had poor health-seeking behavioural practices. Dissatisfaction with the quality of services rendered at the orthodox care may also be another reason for the poor health care seeking behavioural practices among the respondents as shown in this study where more than half of the respondents with good health seeking behavioural practices expressed their dissatisfaction with the orthodox care services. Reasons for their dissatisfaction included length of time of consultation, the attitude of the health workers, unavailability of physicians, dirty hospital environment, hospital services not being well organized, and high hospital bills. All these factors might also be responsible for the non-patronization of orthodox health care services as shown in this study where 46 out of 94 respondents with good health care seeking behavioural practices gave a positive response as regards patronizing the hospital again when sick.
However, the nding in this study is in contrast with the ndings from other studies in a rural part of Wolaita zone, Ethiopia where 57.9% of the elderly had good health care seeking behavior [13]. and Nepal study where 83.7% sought treatment from modern medication with the majority having chronic health problems and health-seeking behaviour associated with nature of disease. [14]. This is in contrast with ndings in Calabar, Nigeria whereby majority were satis ed with services and would repeat the visit [15].
The study also showed that socio-demographic variables like employment status and level of education are important predictors of health-seeking behavioral practices among the respondents as shown by a statistically signi cant relationship between the variables and healthcare-seeking behavioural practices.
This is in keeping with ndings in a rural community in Nigeria [12]. and another Study in Ekiti state Nigeria which reported educational level, nature of the disease, economic status, age, religious beliefs, illness severity as factors associated with the health-seeking behaviors' of elderly [16]. Furthermore a Zambian study among the elderly reported elderly people with lower educational status were more likely to skip treatment than those of middle and higher educational status [17]. Previous studies have also shown that people make better health choices when they are educated. Education is known to be associated with improved health knowledge and better employment opportunities which will create economic empowerment and lead to nancial access to quality healthcare services. This was also in contrast to a study among Indonesia's rural elderly population which reported age was the only demographic factor signi cantly associated with healthcare-seeking behaviour for chronic illness. The utilization of health services was less as the age advances [14]. Another study in Myanmar, Health seeking behavior was associated with the Educational status and income level of the elderly but not with their gender, ethnicity, or religious beliefs[18].
There was a statistically signi cant relationship between the health care seeking behavioural practices and the following as mentioned by the respondents as factors that hindered them from seeking orthodox care namely cost of orthodox care, accessibility to the health facilities, traditional/religious belief, length of time before consultation, con dentiality issue and lack of support from relations. The majority of the respondents who reported they were not challenged by access to health care, their believes, duration of time in accessing care, and support from relations had good health-seeking behaviour but the majority of those that were challenged had poor health-seeking behavioural practices. This is in tandem with the ndings in Calabar where the cost of health care was identi ed to be the major factor hindering the seeking of orthodox care among the elderly [15].Similar results were also found in Ibadan where affordability and proximity were the major hindering factors [19].

Conclusion
In conclusion, the majority of the respondents that fell sick in the preceding year before the study had poor health-seeking behavioural practices. Education and Employment status had a positive in uence on health-seeking behavioural practices. The cost of health care, accessibility to the health facilities, and lack of support from relations are some of the factors mentioned by the majority of the respondents that would hinder their seeking for orthodox care. Government should either make the free or subsidized cost of health care for the elderly especially those living in rural communities. There should be the provision of a monthly stipend for the aged by the government. There is a need to employ more core health workers at all three levels of care. The issue of con dentiality should be taken very seriously by the health workers when interacting with the patient.

Declarations
Ethics approval and consent to participate Ethical approval was obtained from ethical committee of federal Teaching Hospital Ido-Ekiti.The ethical approval number is: ERC/2020/10/14/425B All methods of the research were performed in accordance with the principles of the Declaration of Helsink Consent for publication Not applicable.

Availability of data and material
The data presented in this study are available from the corresponding author upon reasonable request. Respondents' health-seeking behavior