This cross-sectional study was conducted in Odisha, India. According to revenue zones of the state, the state is divided into three divisions such as central division (C.D.), north division (N.D.), south division (S.D.) with 10 districts each. There is one DH, 1or2 SDH and 3-6 CHCs in each district. It was planned to select three districts comprising one from each revenue division. Selected districts of Odisha were Cuttack, Sambalpur and Nabarangapur with proportionate representation from each types of facilities. The only exception was Nabarangapur district as there was no medical college. Within each district, the District hospital, one SDH (if available), two CHCs and two PHCs were selected. Thus a total of three DHHs, three SDHs, six CHCs and six PHCs were covered. Care was taken to include at least one NCD program implemented district. Two tertiary health care facilities Veer Surendra Sai Institute of Medical Sciences and Research, Burla formerly known as (VSS MCH), and Srirama Chandra Bhanja Medical College and Hospital, Cuttack (SCB MCH) were also included. A total of 3377 patients was proposed to be interviewed throughout the study, with proportionate representation from each facility. It was decided to include nearly 160 patients from PHC, 240 patients from CHC, 330 patients from DHH and 850 patients from MCH, thus making grand total of 3040 from three districts. After considering non-response rate of 10%, 3377 patients was proposed to be interviewed over three months of data collection period. Adult patients (more than 18 years) attending the Outpatient Departments (OPD) of sampled health facilities were chosen as study participants through systematic random sampling. A total number of eligible patients were recorded during one week of consultation at each site, the proportion of attendees in one week can be calculated in our sample accordingly. Informed consent of the participant was obtained prior to the interview. Participants were interviewed using a predesigned and pretested (Both Odia and English version) questionnaire while they are waiting to see their doctor or immediately after the consultation. The Odia-version of the instrument was pretested for feasibility on a small sample of non-study patients, and necessary revisions was made. The instrument was then back translated into English, and the questionnaire was evaluated for fidelity to the original intent or purpose of asking each question. Two trained field investigators collected data. The data was collected for the period of three months in 2016.
Certain categories of patients were excluded from self-reporting such as patients too ill to participate, insufficient cognitive ability, any physical or mental disabilities, hence data was collected by interviewing their attendants. To avoid duplication of any patient who have already been interviewed in any of our selected facility previously were excluded. Utmost care was taken to maintain confidentiality on data shared by the patient.
Extensive review of available literature was undertaken to gather all research studies pertaining to morbidity, its estimation, measurement, and correlates and extract relevant information. Inputs from expert group was incorporated. ICPC-3 coding was followed for coding of diseases/symptoms/reasons for encounter.
The study tool includes socio-demographic information (Age, sex, residence, ethnicity, religion, educational level (number of years of schooling), marital status, monthly income from all sources and monthly household expenditure current housing and household composition) and Insurance status including Rashtriya Swasth Bima Yojana (RSBY) and other insurance covered and used.
Unique chief complains were grouped and coded under ICPC-3. Patient having multiple complains were coded separately. Only chief complaints results are presented in this paper. For some of the common symptoms probable ICPC-3 codes were allocated as differential diagnosis for critical analysis. Once consented by all the authors finalized the codes for symptoms and new variables were created for further analysis.
After cleaning of the data, descriptive analysis was done to assess difference in symptom presentation across demographic indicators (age, sex, education, place of living), three levels of health care, behavioral risk factors (smoking, alcohol), and presence of chronic diseases. Data visualization tools were used to explore clustering of symptoms by system. Data entry was completed in the SPSS and data cleaning, analysis was done using R software.
Ethical approval
to conduct this study was obtained from Public Health Foundation of India (PHFI) research ethics committee. Necessary prior official permission was obtained to conduct the study at public health facility. The purpose and procedure of the study was disclosed to the participants and informed consent was obtained from them. All steps were taken to ensure that confidentiality and anonymity are maintained at all times.