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PLOS ONE logoLink to PLOS ONE
. 2015 May 12;10(5):e0125865. doi: 10.1371/journal.pone.0125865

Perceived Morbidity, Healthcare-Seeking Behavior and Their Determinants in a Poor-Resource Setting: Observation from India

Suman Kanungo 1, Kalyan Bhowmik 1, Tanmay Mahapatra 1, Sanchita Mahapatra 1, Uchhal K Bhadra 2, Kamalesh Sarkar 1,*
Editor: Hemachandra Reddy3
PMCID: PMC4428703  PMID: 25965382

Abstract

Background

To control the double burden of communicable and non-communicable diseases (NCDs), in the developing world, understanding the patterns of morbidity and healthcare-seeking is critical. The objective of this cross-sectional study was to determine the distribution, predictors and inter-relationship of perceived morbidity and related healthcare-seeking behavior in a poor-resource setting.

Methods

Between October 2013 and July 2014, 43999 consenting subjects were recruited from 10107 households in Malda district of West Bengal state in India, through multistage random sampling, using probability proportional-to-size. Information on socio-demographics, behaviors, recent ailments, perceived severity and healthcare-seeking were analyzed in SAS-9.3.2.

Results

Recent illnesses were reported by 55.91% (n=24600) participants. Among diagnosed ailments (n=23626), 50.92% (n=12031) were NCDs. Respiratory (17.28%,n=7605)), gastrointestinal (13.48%,n=5929) and musculoskeletal (6.25%,n=2749) problems were predominant. Non-qualified practitioners treated 53.16% (n=13074) episodes. Older children/adolescents [adjusted odds ratio for private healthcare providers(AORPri)=0.76, 95% confidence interval=0.71-0.83) and for Govt. healthcare provider(AORGovt)=0.80(0.68-0.95)], females [AORGovt=0.80(0.73-0.88)], Muslims [AORPri=0.85(0.69-0.76) and AORGovt=0.92(0.87-0.96)], backward castes [AORGovt=0.93(0.91-0.96)] and rural residents [AORPri=0.82(0.75-0.89) and AORGovt=0.72(0.64-0.81)] had lower odds of visiting qualified practitioners. Apparently less severe NCDs [acid-peptic disorders: AORPri=0.41(0.37-0.46) & AORGovt=0.41(0.37-0.46), osteoarthritis: AORPri=0.72(0.59-0.68) & AORGovt=0.58(0.43-0.78)], gastrointestinal [AORPri=0.28(0.24-0.33) & AORGovt=0.69(0.58-0.81)], respiratory [AORPri=0.35(0.32-0.39) & AORGovt=0.46(0.41-0.52)] and skin infections [AORPri=0.65(0.55-0.77)] were also less often treated by qualified practitioners. Better education [AORPri=1.91(1.65-2.22) for ≥graduation], sanitation [AORPri=1.58(1.42-1.75)] and access to safe water [AORPri=1.33(1.05-1.67)] were associated with healthcare-seeking from qualified private practitioners. Longstanding NCDs [chronic obstructive pulmonary diseases: AORPri=1.80(1.46-2.23), hypertension: AORPri=1.94(1.60-2.36), diabetes: AORPri=4.94(3.55-6.87)] and serious infections [typhoid: AORPri=2.86(2.04-4.03)] were also more commonly treated by qualified private practitioners. Potential limitations included temporal ambiguity, reverse causation, generalizability issues and misclassification.

Conclusion

In this poor-resource setting with high morbidity, ailments and their perceived severity were important predictors for healthcare-seeking. Interventions to improve awareness and healthcare-seeking among under-privileged and vulnerable population with efforts to improve the knowledge and practice of non-qualified practitioners probably required urgently.

Introduction

Demographic ageing, unplanned urbanization and unhealthy lifestyles are the major contributors for the changing pattern of disease in recent years, from communicable to non-communicable diseases (NCDs), globally.[13] This epidemiological transition is spreading fast in the developing world, progressively affecting poor, vulnerable and disadvantaged populations.[3,4] Nearly 80% of the current burden of NCDs like cardio-vascular disease, diabetes, cancer and chronic respiratory diseases occurred in low and middle-income countries (LMIC), accounting for 90% of premature (< 60 years) deaths.[1,4,5] As major fraction of this global burden of disease was attributed to preventable risk factors, known behavioral and medical interventions could prevent about 80% of these premature deaths.[3,6] In this era of changing epidemiological trend, the scenario is worsening gradually in LMICs including India where increasing mortality and morbidity are attributable to double burden of communicable and non-communicable diseases in poor-resource settings.[79]

Despite remarkable progress in socio-economic development and having an overarching aim of addressing the health needs through several comprehensive programs, health outcomes in India remained poor. During 2012, approximately 60% deaths were attributed to NCDs (cardiovascular diseases = 26%, chronic respiratory diseases = 13%, cancers = 7%, diabetes = 2% & injuries = 12%) and 28% to communicable, maternal, perinatal and nutritional conditions in this country.[10,11] Evidences suggested that healthcare infrastructure, service delivery system and health outcomes varied considerably across Indian states and for efficient improvement of these parameters, understanding the morbidity patterns and their predictors seemed to be required urgently.[12] It has also been established in recent past that self-perceived morbidity is a reliable measure for estimating the burden especially in a poor-resource setting.[1316]

Individual healthcare-seeking pattern in a community is determined by complex interrelationships between socio-economic and physical environment along with individual characteristics and behaviors.[17] Thus healthcare-seeking pattern and related outcomes have been the focus of community level improvement of health systems worldwide and India is no exception. In last few years, studies have shown that household information based on door-to-door visits were useful for the identification of gaps in perceived morbidity and resultant healthcare-seeking in both urban and rural areas.[18,19] Diverse healthcare-seeking patterns, especially involving non-qualified practitioners and pharmacists often resulted in inadequate treatment, improper dosing and over-the-counter purchase of drugs, frequently culminating into development of antimicrobial resistance and other unfavorable outcomes.[2022]

Relevant researches on morbidity and healthcare-seeking ever conducted in India were mostly limited to urban areas of southern and western part while eastern region remained largely understudied.[23] Malda is one of the poorest districts, situated in the north-eastern part of the state of West Bengal, India; sharing interstate borders with Bihar and Jharkhand, and international border with Bangladesh. Thus international and interstate migration resulted in uneven demographic pressures on the healthcare infrastructure that had to cater 1,870 populations per hospital bed.[24] The district health situation urgently demanded appropriately targeted public health interventions for mitigation of gaps and up-gradation of the healthcare infrastructure to achieve proper control of communicable and non-communicable diseases. For this purpose, proper understanding of the perceived morbidity, related healthcare-seeking and their predictors among residents of this district seemed to be the need of the hour.

Hence, a community-based cross-sectional study was designed involving a representative population of Malda to understand the distribution of the perceived morbidity and healthcare-seeking behavior, their predictors and inter-relationship.

Methods

Ethics Statement

The study protocol was reviewed and approved by the Ethics Committee of the National Institute of Cholera and Enteric Diseases, Kolkata. Written informed consent left thumb impression (for illiterates, in presence of two impartial literate witnesses) was obtained from residents older than 18 years and from the guardians of residents aged 1 to 17 years. Written assent was additionally obtained from residents aged 12 to 17 years.

Recruitment

Based on the 2011 census data, the urban area of the Malda district was divided into two broad urban administrative divisions termed as Municipalities (Old Malda and English Bazar). Each Municipality was further subdivided into smaller administrative units called Wards (19 in Old Malda and 25 in English Bazar). Using probability proportional to size (PPS) determined by the total number of households in the Wards, 4 Wards in Old Malda and 12 Wards in English Bazar were selected randomly. The rural area of the district consisted of 3701 villages and 27 rural towns from which similarly using PPS, 25 villages/census towns were selected randomly. Using an exhaustive house-list of the urban and rural areas, each selected municipal ward and village/rural town was categorized into several segments (considered as Primary Sampling Unit: PSU), each having 125 households (defined as those who shared the cooking-pot in each dwelling). Next, 4012 urban and 6095 rural households (maintaining the population ratio) were selected from the whole district, through multistage random sampling, using PPS. Thus, 16 municipal wards in urban and 24 villages/towns in rural area were selected. In each selected ward/village from the list of segments two were selected randomly and all households were surveyed there after collecting written informed consent from the residents.

Interview

All the individuals residing in the selected households were interviewed at home by trained interviewers, using a structured, pre-tested, bi-lingual (English and local language: Bengali) questionnaire. Information was collected on socio-demographic and related variables such as age, gender, religion, caste, education level and occupation of the household members, maximum education level among adults in the house, house ownership, residential area, type and location of water source, water treatment at home, material used for cooking and domestic light source. Housing type was classified as Kachha (if neither roof/walls/floors was made of permanent materials like bricks/cement/stone), Pacca (if roof, walls and floors all were made of permanent materials like bricks/cement/stone) and Semi-pacca (for any combinations between Kaccha and Pacca builts regarding roof, walls and floors). Sanitation level of toilet use practices were categorized as poor (if the household had no toilet and the members used open space/field/jungle for defecation), good (for households having toilets with flush to piped sewer system/flush to septic tank) and all others (flush to pit latrine/flush to elsewhere/all other types of pit latrine etc.) as average.

Based on the information regarding household assets (enquired using an appropriate list of assets), number of cattle, goats/sheep, poultry, place for keeping them and the aforementioned household information, wealth index was calculated by using relative weights for each and then the cumulative wealth index scores were log-transformed and divided into quintiles of socio-economic status: SES (very poor, poor, lower middle, upper middle and upper) based on the percentile distribution.

For all the members of the selected households, information regarding last three episodes of ailments that forced them to seek some healthcare services within last two months was collected. Occurrence, perceived severity and healthcare-seeking behavior (visited non-qualified/qualified private sector/qualified Govt. sector practitioners) regarding specific NCDs like: acid peptic disorder (APD) or peptic ulcer disorder (PUD), chronic obstructive pulmonary disease (COPD), hypertension (HTN), diabetes mellitus (DM), anemia and osteoarthritis (OA) as well as communicable diseases like: gastroenteritis, respiratory tract infection (RTI), typhoid and skin infections were also collected.

Data analyses

Thus between October 2013 and July 2014, 43999 individuals (with approximately 8% non-response) were recruited from 10107 households (4012 urban and 6095 rural) and collected data were analyzed using Statistical Analysis System (SAS) version 9.3.2. Distribution of the socio-demographic characteristics, morbidity pattern and healthcare-seeking were determined by conducting descriptive analyses using survey frequency procedure to determine overall and stratified frequencies, proportions and corresponding 95% confidence intervals (95%CI). Bivariate and multivariate logistic regression analyses were next conducted to determine unadjusted (OR) and adjusted (for age, gender, religion, caste, individual and familial education, occupational type, residential area, sanitation and SES) odds ratios (AOR) as the measures of association (with corresponding 95%CIs) between study variables. Multinomial logistic regressions [25] were used where the dependent variables had more than two categories.

Results

Among 43999 subjects, majorities were aged 18–40 yrs (40.74%, n = 17925), male (50.65%, n = 22287), Hindu (67.89%, n = 29869), general caste (42.11%, n = 18526) and educated up to secondary level (33.44%, n = 12782). For 38.82% (n = 17080). Maximum adult education in the household was also up to secondary level, 95.73% (n = 42122) stayed in own house, 39.60% (n = 15888) were in sedentary work and 62.60% (n = 27543) lived in rural areas. (Table 1)

Table 1. Overall and stratified (across the strata of health-seeking behavior) distribution of socio-demographic characteristics among recruited residents of Malda, West Bengal, India (N = 43999).

Socio-demographics Categories Total (N = 43999) Didn’t report any recent morbidity (n = 19404) Reported to have recent morbidity & care sought from (Practitioner type)
Non-qualified (13074) Qualified, private sector (8368) Qualified, Govt. sector (3153)
n Percentage (95%CI) n Percentage (95%CI) n Percentage (95%CI) n Percentage (95%CI) n Percentage (95%CI)
Age group of the subject <5 years 3873 8.80(8.54–9.07) 1298 6.69(6.34–7.04) 1375 10.52(9.99–11.04) 967 11.56(10.87–12.24) 233 7.39(6.48–8.30)
5–<18 years 12043 27.37(26.95–27.79) 7008 36.12(35.44–36.79) 3013 23.05(22.32–23.77) 1359 16.24(15.45–17.03) 663 21.03(19.6–22.45)
18–40 years 17925 40.74(40.28–41.20) 8484 43.72(43.02–44.42) 5208 39.83(39.00–40.67) 3073 36.72(35.69–37.76) 1160 36.79(35.11–38.47)
41–60 years 7911 17.98(17.62–18.34) 2154 11.10(10.66–11.54) 2741 20.97(20.27–21.66) 2195 26.23(25.29–27.17) 821 26.04(24.51–27.57)
>60 years 2247 5.11(4.90–5.31) 460 2.37(2.16–2.58) 737 5.64(5.24–6.03) 774 9.25(8.63–9.87) 276 8.75(7.77–9.74)
Gender Male 22287 50.65(50.19–51.12) 10624 54.75(54.05–55.45) 6073 46.45(45.60–47.31) 4000 47.8(46.73–48.87) 1590 50.43(48.68–52.17)
Female 21712 49.35(48.88–49.81) 8780 45.25(44.55–45.95) 7001 53.55(52.69–54.40) 4368 52.2(51.13–53.27) 1563 49.57(47.83–51.32)
Religion Hindu 29869 67.89(67.45–68.32) 12843 66.19(65.52–66.85) 8860 67.77(66.97–68.57) 6011 71.83(70.87–72.80) 2155 68.35(66.72–69.97)
Muslim 13975 31.76(31.33–32.20) 6498 33.49(32.82–34.15) 4158 31.8(31.01–32.60) 2335 27.90(26.94–28.87) 984 31.21(29.59–32.83)
Christian 144 0.33(0.27–0.38) 58 0.30(0.22–0.38) 53 0.41(0.30–0.51) 22 0.26(0.15–0.37) 11 0.35(0.14–0.55)
Sikh 11 0.03(0.01–0.04) 5 0.03(0.00–0.05) 3 0.02(0.00–0.05) - - 3 0.10(0.00–0.20)
Caste Scheduled caste 16104 36.60(36.15–37.05) 6918 35.65(34.98–36.33) 4962 37.95(37.12–38.79) 2889 34.52(33.51–35.54) 1335 42.34(40.62–44.07)
Scheduled tribe 1589 3.61(3.44–3.79) 709 3.65(3.39–3.92) 623 4.77(4.40–5.13) 182 2.18(1.86–2.49) 75 2.38(1.85–2.91)
Other backward class 7780 17.68(17.33–18.04) 3611 18.61(18.06–19.16) 2141 16.38(15.74–17.01) 1499 17.91(17.09–18.74) 529 16.78(15.47–18.08)
General 18526 42.11(41.64–42.57) 8166 42.08(41.39–42.78) 5348 40.91(40.06–41.75) 3798 45.39(44.32–46.45) 1214 38.50(36.80–40.20)
Education level of the subject Illiterate 9557 25.00(24.57–25.44) 3075 17.87(17.3–18.44) 3693 33.29(32.42–34.17) 1795 25.24(24.23–26.25) 994 35.39(33.62–37.16)
Primary 11916 31.17(30.71–31.64) 5856 34.03(33.32–34.73) 3462 31.21(30.35–32.07) 1756 24.69(23.69–25.69) 842 29.98(28.28–31.67)
Secondary 12782 33.44(32.97–33.91) 6210 36.08(35.37–36.8) 3223 29.06(28.21–29.90) 2564 36.05(34.94–37.17) 785 27.95(26.29–29.61)
Higher-secondary 2086 5.46(5.23–5.69) 1069 6.21(5.85–6.57) 404 3.64(3.29–3.99) 486 6.83(6.25–7.42) 127 4.52(3.75–5.29)
Graduation and above 1882 4.92(4.71–5.14) 1000 5.81(5.46–6.16) 310 2.79(2.49–3.10) 511 7.19(6.58–7.79) 61 2.17(1.63–2.71)
Maximum educational level among adult members in the household Illiterate 6838 15.54(15.20–15.88) 2740 14.12(13.63–14.61) 2611 19.97(19.29–20.66) 881 10.53(9.87–11.19) 606 19.22(17.84–20.60)
Primary 9130 20.75(20.37–21.13) 3939 20.3(19.73–20.87) 3130 23.94(23.21–24.67) 1345 16.07(15.29–16.86) 716 22.71(21.25–24.17)
Secondary 17080 38.82(38.36–39.27) 7556 38.94(38.25–39.63) 5020 38.40(37.56–39.23) 3291 39.33(38.28–40.38) 1213 38.47(36.77–40.17)
Higher-secondary 4957 11.27(10.97–11.56) 2315 11.93(11.47–12.39) 1188 9.09(8.59–9.58) 1121 13.40(12.67–14.13) 333 10.56(9.49–11.63)
Graduation and above 5994 13.62(13.30–13.94) 2854 14.71(14.21–15.21) 1125 8.60(8.12–9.09) 1730 20.67(19.81–21.54) 285 9.04(8.04–10.04)
House ownership Owned 42122 95.73(95.55–95.92) 18661 96.17(95.9–96.44) 12533 95.86(95.52–96.20) 7951 95.02(94.55–95.48) 2977 94.42(93.62–95.22)
Rented 1421 3.23(3.06–3.39) 558 2.88(2.64–3.11) 399 3.05(2.76–3.35) 338 4.04(3.62–4.46) 126 4.00(3.31–4.68)
Others 456 1.04(0.94–1.13) 185 0.95(0.82–1.09) 142 1.09(0.91–1.26) 79 0.94(0.74–1.15) 50 1.59(1.15–2.02)
Occupational type Sedentary 15888 39.60(39.12–40.07) 8531 47.12(46.39–47.84) 3828 32.72(31.87–33.57) 2534 34.24(33.16–35.32) 995 34.08(32.36–35.80)
Moderate worker 12907 32.17(31.71–32.62) 4746 26.21(25.57–26.85) 4097 35.02(34.16–35.88) 3032 40.97(39.85–42.09) 1032 35.34(33.61–37.08)
Hard Worker 11331 28.24(27.80–28.68) 4829 26.67(26.03–27.31) 3774 32.26(31.41–33.11) 1835 24.79(23.81–25.78) 893 30.58(28.91–32.25)
Residential area Rural 27543 62.60(62.15–63.05) 12192 62.83(62.15–63.51) 8959 68.53(67.73–69.32) 4475 53.48(52.41–54.55) 1917 60.80(59.09–62.50)
Urban 16456 37.40(36.95–37.85) 7212 37.17(36.49–37.85) 4115 31.47(30.68–32.27) 3893 46.52(45.45–47.59) 1236 39.20(37.5–40.91)
Water source Unsafe 1455 3.31(3.14–3.47) 678 3.49(3.24–3.75) 426 3.26(2.95–3.56) 238 2.84(2.49–3.20) 113 3.58(2.93–4.23)
May be unsafe 40208 91.38(91.12–91.65) 17671 91.07(90.67–91.47) 12258 93.76(93.34–94.17) 7375 88.13(87.44–88.83) 2904 92.10(91.16–93.04)
Safe 2336 5.31(5.10–5.52) 1055 5.44(5.12–5.76) 390 2.98(2.69–3.27) 755 9.02(8.41–9.64) 136 4.31(3.60–5.020)
Location of water source Elsewhere 22140 50.32(49.85–50.79) 9657 49.77(49.06–50.47) 6497 49.69(48.84–50.55) 4394 52.51(51.44–53.58) 1592 50.49(48.75–52.24)
In own yard/plot 15209 34.57(34.12–35.01) 6757 34.82(34.15–35.49) 4649 35.56(34.74–36.38) 2684 32.07(31.07–33.07) 1119 35.49(33.82–37.16)
In own dwelling 6650 15.11(14.78–15.45) 2990 15.41(14.90–15.92) 1928 14.75(14.14–15.35) 1290 15.42(14.64–16.19) 442 14.02(12.81–15.23)
Water treatment at home No 41825 95.06(94.86–95.26) 18391 94.78(94.47–95.09) 12689 97.06(96.77–97.35) 7719 92.24(91.67–92.82) 3026 95.97(95.29–96.66)
Yes 2174 4.94(4.74–5.14) 1013 5.22(4.91–5.53) 385 2.94(2.66–3.23) 649 7.76(7.18–8.33) 127 4.03(3.34–4.71)
Sanitation level of the practices regarding toilet use Poor 11856 26.95(26.53–27.36) 5133 26.45(25.83–27.07) 4282 32.75(31.95–33.56) 1523 18.20(17.37–19.03) 918 29.12(27.53–30.70)
Average 18668 42.43(41.97–42.89) 8287 42.71(42.01–43.40) 5634 43.09(42.24–43.94) 3338 39.89(38.84–40.94) 1409 44.69(42.95–46.42)
Good 13475 30.63(30.20–31.06) 5984 30.84(30.19–31.49) 3158 24.15(23.42–24.89) 3507 41.91(40.85–42.97) 826 26.20(24.66–27.73)
Material used for cooking Crop residue/Cow dung cake 13441 30.55(30.12–30.99) 6084 31.36(30.71–32.01) 4610 35.27(34.45–36.09) 1900 22.71(21.81–23.61) 847 26.86(25.32–28.41)
Firewood/Coal/lignite/charcoal 17376 39.50(39.04–39.96) 7624 39.30(38.61–39.99) 5525 42.27(41.42–43.12) 2758 32.97(31.96–33.97) 1469 46.59(44.85–48.33)
Kerosene 379 0.86(0.78–0.95) 156 0.80(0.68–0.93) 120 0.92(0.75–1.08) 73 0.87(0.67–1.07) 30 0.95(0.61–1.29)
LPG/PNG/Electricity 12794 29.08(28.66–29.51) 5536 28.54(27.90–29.17) 2816 21.54(20.84–22.25) 3635 43.45(42.39–44.51) 807 25.59(24.07–27.12)
Housing type Kachha 15377 34.97(34.52–35.41) 6808 35.10(34.43–35.78) 5260 40.26(39.42–41.10) 2114 25.28(24.34–26.21) 1195 37.90(36.21–39.59)
Semi-pucca 16639 37.84(37.38–38.29) 7152 36.88(36.20–37.56) 5133 39.29(38.45–40.12) 3023 36.14(35.11–37.17) 1331 42.21(40.49–43.94)
Pacca 11961 27.20(26.78–27.61) 5434 28.02(27.39–28.65) 2673 20.46(19.77–21.15) 3227 38.58(37.54–39.63) 627 19.89(18.49–21.28)
Light source at the household No lighting 62 0.14(0.11–0.18) 26 0.13(0.08–0.19) 20 0.15(0.09–0.22) 8 0.10(0.03–0.16) 8 0.25(0.08–0.43)
Kerosene 4802 10.92(10.62–11.21) 2032 10.47(10.04–10.90) 1754 13.42(12.83–14.00) 585 6.99(6.44–7.54) 431 13.67(12.47–14.87)
Solar 32 0.07(0.05–0.10) 14 0.07(0.03–0.11) 9 0.07(0.02–0.11) 7 0.08(0.02–0.15) 2 0.06(0.00–0.15)
Electricity 39098 88.87(88.58–89.17) 17330 89.32(88.89–89.76) 11288 86.36(85.77–86.95) 7768 92.83(92.28–93.38) 2712 86.01(84.80–87.22)
Socio-economic status (SES) Very poor 9186 20.88(20.50–021.26) 3657 18.85(18.30–19.40) 3452 26.40(25.65–27.16) 1288 15.39(14.62–16.17) 789 25.02(23.51–26.54)
Poor 10157 23.08(22.69–23.48) 4216 21.73(21.15–22.31) 3085 23.60(22.87–24.32) 2022 24.16(23.25–25.08) 834 26.45(24.91–27.99)
Lower middle 7065 16.06(15.71–16.40) 3112 16.04(15.52–16.55) 1948 14.90(14.29–15.51) 1513 18.08(17.26–18.91) 492 15.60(14.34–16.87)
Upper middle 9038 20.54(20.16–20.92) 4182 21.55(20.97–22.13) 2338 17.88(17.23–18.54) 1991 23.79(22.88–24.71) 527 16.71(15.41–18.02)
Upper 8553 19.44(19.07–19.81) 4237 21.84(21.25–22.42) 2251 17.22(16.57–17.86) 1554 18.57(17.74–19.40) 511 16.21(14.92–17.49)

n = Stratum specific number of participants; 95%CI = 95% Confidence Interval

Only 5.31% (n = 2336) were drinking safe water, 50.32% (n = 22140) had to bring drinking water from outside, 95.06% (n = 41825) were not doing any water treatment at home, 29.08% (n = 12794) were using gas/electricity for cooking, 27.20% (n = 11961) were living in pacca houses. Electricity was the source of lighting at home for 88.87% (n = 39098), regarding toilet use 30.63% (n = 13475) had good sanitary practices and overall 19.44% (n = 8553) belonged to upper SES. Overall and stratified (across healthcare-seeking patterns) socio-demographic distribution are presented in Table 1.

Regarding the distribution of self-perceived most recent (within past 2 month) morbidity, 44.09% (n = 19399) did not suffer from any such recently while for 17.28% (n = 7605), 13.48% (n = 5929) and 6.25% (n = 2749) residents the most recent morbidity was related to respiratory, gastrointestinal and musculoskeletal system respectively. Among the most recent ailments, NCDs were 50.92% (n = 12031), 53.16% (n = 13074) episodes were treated by non-qualified practitioners, 34.02% (n = 8368) by qualified practitioner from private sector and only 12.82% (n = 3153) by qualified practitioner from Govt. sector. Non-qualified practitioners were treating more communicable diseases compared to NCDs [57.52% (n = 7194) vs. 42.48% (n = 5313)]. (Table 2)

Table 2. Overall and stratified (across the strata of health-seeking behavior) distribution of self-perceived morbidities among recruited residents of Malda, West Bengal, India (N = 43999).

Distribution of all types of self-perceived morbidity* (based on most recent ailments)** Total Care sought from (Practitioner type)
Non-qualified Qualified, private sector Qualified, Govt. sector
n Percentage (95%CI) n Percentage (95%CI) n Percentage (95%CI) n Percentage (95%CI)
Organ/System/Function involved None 19399 44.09(43.63–44.55)
Respiratory 7605 17.28(16.93–17.64) 4760 36.41(35.58–37.23) 2031 24.27(23.35–25.19) 814 25.82(24.29–27.35)
Gastrointestinal 5929 13.48(13.16–13.79) 3416 26.13(25.38–26.88) 1763 21.07(20.19–21.94) 749 23.76(22.27–25.24)
Musculoskeletal 2749 6.25(6.02–6.47) 1451 11.10(10.56–11.64) 966 11.54(10.86–12.23) 332 10.53(9.46–11.6)
Hematological/Immunological/Metabolic/Parasitic disorders 1985 4.51(4.32–4.71) 1102 8.43(7.95–8.91) 587 7.01(6.47–7.56) 295 9.36(8.34–10.37)
Darmatological 1419 3.23(3.06–3.39) 731 5.59(5.20–5.99) 463 5.53(5.04–6.02) 223 7.07(6.18–7.97)
Hypertension 761 1.73(1.61–1.85) 168 1.29(1.09–1.48) 493 5.89(5.39–6.40) 100 3.17(2.56–3.78)
Neurological 605 1.38(1.27–1.48) 253 1.94(1.70–2.17) 241 2.88(2.52–3.24) 111 3.52(2.88–4.16)
Eye/Nose/Throat related 553 1.26(1.15–1.36) 239 1.83(1.60–2.06) 231 2.76(2.41–3.11) 83 2.63(2.07–3.19)
Reproductive 552 1.25(1.15–1.36) 221 1.69(1.47–1.91) 265 3.17(2.79–3.54) 66 2.09(1.59–2.59)
Dental 490 1.11(1.02–1.21) 320 2.45(2.18–2.71) 116 1.39(1.14–1.64) 54 1.71(1.26–2.17)
Ophthalmological 476 1.08(0.99–1.18) 83 0.63(0.50–0.77) 293 3.50(3.11–3.90) 100 3.17(2.56–3.78)
Diabetes mellitus 374 0.85(0.76–0.94) 38 0.29(0.20–0.38) 282 3.37(2.98–3.76) 54 1.71(1.26–2.17)
Urological 267 0.61(0.53–0.68) 37 0.28(0.19–0.37) 189 2.26(1.94–2.58) 41 1.30(0.90–1.70)
Cardiovascular 194 0.44(0.38–0.50) 24 0.18(0.11–0.26) 128 1.53(1.27–1.79) 42 1.33(0.93–1.73)
Thyroid disorders 178 0.40(0.35–0.46) 8 0.06(0.02–0.10) 152 1.82(1.53–2.10) 17 0.54(0.28–0.79)
Cancer 67 0.15(0.12–0.19) 31 0.24(0.15–0.32) 26 0.31(0.19–0.43) 10 0.32(0.12–0.51)
Injury/Bites 53 0.12(0.09–0.15) 12 0.09(0.04–0.14) 13 0.16(0.07–0.24) 28 0.89(0.56–1.22)
Psychiatric 50 0.11(0.08–0.15) 4 0.03(0.00–0.06) 40 0.48(0.33–0.63) 6 0.19(0.04–0.34)
Poisoning 2 <0.01(0.00–0.01) - - - - 2 0.06(0.00–0.15)
Type of morbidity Communicable diseases 11595 49.08(48.44–49.71) 7194 57.52(56.65–58.39) 2947 36.59(35.53–37.64) 1452 47.47(45.70–49.24)
Non-communicable diseases 12031 50.92(50.29–51.56) 5313 42.48(41.61–43.35) 5108 63.41(62.36–64.47) 1607 52.53(50.76–54.30)
Treated by Non-qualified practitioner 13074 53.16(52.53–53.78)
Qualified practitioner from private sector 8368 34.02(33.43–34.62)
Qualified practitioner from Govt. sector 3153 12.82(12.40–13.24)
Specific ailments (Based on last three episodes of ill-health) No. & Percentage of subjects who recently suffered Care sought from (Practitioner type)
Non-qualified Qualified, private sector Qualified, Govt. sector
n Percentage (95%CI) n Percentage (95%CI) n Percentage (95%CI) n Percentage (95%CI)
Respiratory tract infection 6734 19.01(18.60–19.42) 4614 50.12(49.1–51.15) 1552 34.67(33.27–36.06) 568 34.76(32.45–37.07)
Peptic ulcer disease/Acid peptic disorder 2554 8.18(7.87–8.48) 1700 18.47(17.68–19.26) 661 14.76(13.72–15.80) 193 11.81(10.25–13.38)
Gastroenteritis 1977 6.45(6.17–6.72) 1337 14.52(13.80–15.24) 367 8.20(7.39–9.00) 273 16.71(14.90–18.52)
Skin infections & related disorder 1070 3.60(3.38–3.81) 595 6.46(5.96–6.97) 315 7.04(6.29–7.79) 160 9.79(8.35–11.23)
Hypertension 793 2.69(2.51–2.88) 184 2.00(1.71–2.28) 510 11.39(10.46–12.32) 99 6.06(4.90–7.22)
Chronic obstructive pulmonary 601 2.05(1.89–2.21) 170 1.85(1.57–2.12) 307 6.86(6.12–7.60) 124 7.59(6.30–8.87)
Osteoarthritis 559 1.91(1.75–2.07) 311 3.38(3.01–3.75) 198 4.42(3.82–5.03) 50 3.06(2.22–3.90)
Diabetes mellitus 408 1.40(1.27–1.54) 44 0.48(0.34–0.62) 311 6.95(6.20–7.69) 53 3.24(2.38–4.10)
Anaemia 365 1.26(1.13–1.38) 192 2.09(1.79–2.38) 128 2.86(2.37–3.35) 45 2.75(1.96–3.55)
Typhoid 255 0.88(0.77–0.99) 58 0.63(0.47–0.79) 128 2.86(2.37–3.35) 69 4.22(3.25–5.20)
Variables Categories No. & Percentage of subjects who recently suffered Treatment supervised by (Practitioner type)
Non-qualified Qualified, private sector Qualified, Govt. sector
n Percentage (95%CI) n Percentage (95%CI) n Percentage (95%CI) n Percentage (95%CI)
Perceived severity Easily recovered/ Well controlled 9589 62.61(61.84–63.37) 6493 70.54(69.61–71.47) 2146 47.93(46.47–49.40) 950 58.14(55.75–60.53)
Partially recovered/not fully controlled 1860 12.14(11.63–12.66) 1161 12.61(11.93–13.29) 502 11.21(10.29–12.14) 197 12.06(10.48–13.64)
Not Recovered with initial treatment 3867 25.25(24.56–25.94) 1551 16.85(16.08–17.61) 1829 40.85(39.41–42.29) 487 29.80(27.58–32.02)

n = Stratum specific number of participants; 95%CI = 95% Confidence Interval

* Excluding 291 undiagnosed and 683 “others”

** Group totals may not be identical due to missing values

Based on last three healthcare-seeking episodes, among specific ailments (suffered or not), 19.01% (n = 6734) suffered from RTI, 8.18% (n = 2554) had PUD/APD, 6.45% (n = 1977) experienced gastroenteritis while 3.60% (n = 1070) had some skin problems. Among subjects visiting nonqualified practitioners, only 16.85% (n = 1551) perceived their ailments as severe while this fraction for private sector qualified practitioners, was 40.85% (n = 1829). (Table 2)

Association of socio-demographics with morbidity and healthcare-seeking are presented in Tables 3 and 4. Compared to 18–40 years old, subjects aged 5–18 years were less likely to suffer from APD [AOR = 0.24(0.19–0.30)], COPD [AOR = 0.55(0.38–0.81)], HTN [AOR = 0.02(<0.01–0.11)], DM [AOR = 0.02(<0.01–0.15)], anemia [AOR = 0.16(0.09–0.29)] and OA [AOR = 0.13(0.06–0.29)] but more prone to RTI [AOR = 1.13(1.01–1.27)]. Persons aged 41–60 and >60 years had more APD [AOR41–60 = 2.01(1.82–2.23), AOR>60 = 2.86(2.41–3.39)], COPD [AOR41–60 = 4.80 (3.79–6.09), AOR>60 = 13.13(9.89–17.44)], HTN [AOR41–60 = 12.86(10.29–16.07), AOR>60 = 26.28(20.12–34.31)], DM [AOR41–60 = 6.82(5.29–8.80), AOR>60 = 12.40(8.86–17.35)], OA [AOR41–60 = 12.88(9.93–16.71), AOR>60 = 18.58(13.36–25.86)], gastroenteritis [AOR41–60 = 1.50(1.29–1.75), AOR>60 = 2.44(1.92–3.11)] and RTI [AOR41–60 = 1.49(1.36–1.62), AOR>60 = 1.82(1.56–2.13)].

Table 3. Association (both unadjusted and adjusted) of socio-demographic characteristics with self-perceived specific non-communicable morbidities and their severity among recruited residents of Malda, West Bengal, India (N = 43999).

Socio-demographics Categories Measurement (Unadj = Bivariate Adj = Multivariate) Suffering from specific non-communicable ailments (Based on last three episodes of ill-health) Perceived severity of disease (Ref = Mild)
Acid peptic disorder COPD Hypertension Diabetes Mellitus Anemia Osteoarthritis Moderate Severe
OR (95%CI) p value OR (95%CI) p value OR (95%CI) p value OR (95%CI) p value OR (95%CI) p value OR (95%CI) p value OR (95%CI) p value OR (95%CI) p value
Age group of the subject (Ref = <18–40years) <5 years Unadj 0.11(0.07–0.17) <.0001 - - 0.07(0.01–0.47) 0.0069 - - 0.09(0.03–0.27) <.0001 - - 0.27(0.22–0.34) <.0001 0.65(0.57–0.74) <.0001
Adj - - - - - - - - - - - - - - -
5–<18 years Unadj 0.17(0.15–0.21) <.0001 0.87(0.65–1.17) 0.3613 0.03(0.01–0.11) <.0001 0.03(0.01–0.12) <.0001 0.12(0.08–0.19) <.0001 0.15(0.07–0.31) <.0001 0.39(0.33–0.45) <.0001 0.53(0.47–0.60) <.0001
Adj 0.24(0.19–0.30) <.0001 0.55(0.38–0.81) 0.0021 0.02(<0.01–0.11) <.0001 0.02(<0.01–0.15) 0.0001 0.16(0.09–0.29) <.0001 0.13(0.06–0.29) <.0001 0.33(0.25–0.42) <.0001 0.52(0.43–0.62) <.0001
41–60 years Unadj 1.97(1.80–2.17) <.0001 5.11(4.08–6.40) <.0001 11.57(9.37–14.28) <.0001 6.59(5.18–8.37) <.0001 0.83(0.64–1.08) 0.1598 13.01(10.16–16.65) <.0001 1.80(1.59–2.03) <.0001 2.54(2.30–2.81) <.0001
Adj 2.01(1.82–2.23) <.0001 4.80(3.79–6.09) <.0001 12.86(10.29–16.07) <.0001 6.82(5.29–8.80) <.0001 0.95(0.72–1.27) 0.7498 12.88(9.93–16.71) <.0001 1.70(1.49–1.95) <.0001 2.34(2.10–2.61) <.0001
>60 years Unadj 2.48(2.13–2.89) <.0001 17.12(13.41–21.85) <.0001 28.74(22.76–36.29) <.0001 11.77(8.77–15.81) <.0001 0.46(0.24–0.90) 0.0228 21.29(15.96–28.41) <.0001 3.01(2.51–3.60) <.0001 5.02(4.35–5.79) <.0001
Adj 2.86(2.41–3.39) <.0001 13.13(9.89–17.44) <.0001 26.28(20.12–34.31) <.0001 12.40(8.86–17.35) <.0001 0.53(0.26–1.08) 0.0824 18.58(13.36–25.86) <.0001 2.63(2.14–3.22) <.0001 4.25(3.61–5.00) <.0001
Gender (Ref = Male) Female Unadj 1.66(1.52–1.80) <.0001 0.71(0.60–0.84) <.0001 1.45(1.26–1.67) <.0001 0.76(0.62–0.92) 0.0056 13.11(8.91–19.29) <.0001 2.49(2.08–2.99) <.0001 1.18(1.06–1.30) 0.0014 1.11(1.03–1.19) 0.0090
Adj 1.60(1.45–1.77) <.0001 0.59(0.48–0.73) <.0001 1.53(1.28–1.83) <.0001 0.73(0.57–0.92) 0.0085 16.26(10.75–24.59) <.0001 2.58(2.07–3.22) <.0001 1.10(0.97–1.25) 0.1302 1.07(0.96–1.18) 0.2139
Religion (Ref = Hindu) Muslim Unadj 0.74(0.68–0.82) <.0001 0.81(0.67–0.97) 0.0191 0.46(0.38–0.56) <.0001 0.70(0.56–0.87) 0.0016 0.97(0.78–1.21) 0.7997 0.81(0.67–0.97) 0.0254 1.32(1.19–1.47) <.0001 0.76(0.70–0.83) <.0001
Adj 0.77(0.69–0.87) <.0001 0.98(0.77–1.25) 0.8697 1.01(0.81–1.27) 0.9039 1.40(1.06–1.85) 0.0174 0.94(0.71–1.25) 0.6795 0.90(0.71–1.13) 0.3524 1.37(1.19–1.57) <.0001 0.98(0.87–1.10) 0.6786
Others Unadj 0.53(0.21–1.29) 0.1607 1.38(0.44–4.35) 0.5872 0.31(0.04–2.19) 0.2375 - - 2.40(0.75–7.61) 0.1385 0.98(0.24–4.00) 0.9805 1.46(0.73–2.93) 0.2874 0.47(0.22–1.00) 0.0513
Adj 0.67(0.27–1.67) 0.3870 2.63(0.80–8.61) 0.1114 1.15(0.15–8.63) 0.8928 - - 2.11(0.64–6.99) 0.2227 1.22(0.28–5.32) 0.7901 1.38(0.61–3.14) 0.4396 0.58(0.23–1.44) 0.2396
Caste (Ref = General) SC/ST/OBC Unadj 0.79(0.73–0.86) <.0001 1.04(0.88–1.22) 0.6611 0.66(0.57–0.76) <.0001 0.71(0.58–0.86) 0.0005 0.83(0.67–1.02) 0.0743 1.03(0.87–1.22) 0.7427 0.90(0.81–1.00) 0.0393 0.89(0.82–0.96) 0.0017
Adj 0.74(0.67–0.81) <.0001 1.00(0.82–1.22) 0.9857 0.82(0.69–0.97) 0.0184 0.95(0.76–1.18) 0.6212 0.77(0.60–0.98) 0.0348 0.98(0.80–1.20) 0.8228 1.06(0.93–1.21) 0.3630 0.96(0.87–1.06) 0.4100
Education level of the subject (Ref = Illiterate) Primary Unadj 0.46(0.41–0.51) <.0001 0.36(0.29–0.44) <.0001 0.37(0.30–0.46) <.0001 0.53(0.40–0.72) <.0001 0.50(0.39–0.66) <.0001 0.27(0.21–0.33) <.0001 0.50(0.43–0.57) <.0001 0.63(0.57–0.70) <.0001
Adj 1.02(0.90–1.17) 0.7187 0.84(0.65–1.09) 0.1902 1.12(0.88–1.43) 0.3650 1.25(0.90–1.74) 0.1811 1.07(0.78–1.48) 0.6716 1.10(0.86–1.41) 0.4628 0.85(0.73–1.01) 0.0569 0.96(0.84–1.09) 0.4963
Secondary Unadj 0.55(0.50–0.61) <.0001 0.35(0.29–0.44) <.0001 0.70(0.59–0.84) <.0001 0.92(0.71–1.18) 0.4919 0.53(0.41–0.69) <.0001 0.24(0.19–0.30) <.0001 0.55(0.48–0.63) <.0001 0.82(0.74–0.91) 0.0002
Adj 1.08(0.94–1.23) 0.2987 0.80(0.61–1.05) 0.1124 1.47(1.16–1.86) 0.0014 1.42(1.03–1.95) 0.0334 1.06(0.75–1.51) 0.7279 0.93(0.71–1.23) 0.6287 0.84(0.71–0.99) 0.0416 0.98(0.86–1.13) 0.8158
Higher-secondary Unadj 0.48(0.39–0.58) <.0001 0.28(0.17–0.45) <.0001 0.85(0.63–1.14) 0.2677 1.16(0.78–1.73) 0.4734 0.37(0.21–0.66) 0.0007 0.19(0.11–0.32) <.0001 0.49(0.37–0.66) <.0001 0.88(0.73–1.08) 0.2180
Adj 0.98(0.76–1.25) 0.8451 0.55(0.31–0.95) 0.0328 1.35(0.93–1.97) 0.1181 1.33(0.81–2.18) 0.2592 0.99(0.49–2.02) 0.9820 0.68(0.38–1.22) 0.1959 0.53(0.38–0.75) 0.0003 0.76(0.59–0.98) 0.0308
Graduation and above Unadj 0.53(0.43–0.65) <.0001 0.43(0.29–0.65) <.0001 1.31(1.01–1.70) 0.0447 1.63(1.13–2.36) 0.0098 0.26(0.13–0.53) 0.0002 0.14(0.07–0.26) <.0001 0.55(0.41–0.74) 0.0001 1.32(1.09–1.60) 0.0054
Adj 1.04(0.79–1.37) 0.7804 0.81(0.47–1.41) 0.4625 1.63(1.11–2.39) 0.0119 1.43(0.86–2.37) 0.1716 0.98(0.40–2.45) 0.9730 0.53(0.26–1.08) 0.0800 0.58(0.39–0.85) 0.0053 0.85(0.65–1.11) 0.2313
Maximum educational level among adult household members (Ref = Illiterate) Primary Unadj 0.88(0.77–1.01) 0.0680 0.76(0.58–0.99) 0.0442 0.96(0.68–1.36) 0.8082 1.43(0.86–2.39) 0.1718 0.99(0.72–1.38) 0.9733 0.67(0.50–0.88) 0.0050 0.89(0.76–1.04) 0.1430 1.19(1.05–1.36) 0.0088
Adj 0.83(0.71–0.98) 0.0241 0.78(0.57–1.05) 0.1025 0.88(0.60–1.29) 0.5239 1.22(0.70–2.11) 0.4863 0.94(0.65–1.37) 0.7515 0.69(0.50–0.95) 0.0217 0.99(0.82–1.20) 0.9135 1.25(1.06–1.47) 0.0072
Secondary Unadj 0.93(0.82–1.05) 0.2368 0.79(0.63–1.00) 0.0459 1.75(1.31–2.34) 0.0002 2.45(1.56–3.85) <.0001 0.87(0.65–1.17) 0.3661 0.76(0.60–0.97) 0.0280 0.87(0.76–1.00) 0.0492 1.32(1.18–1.49) <.0001
Adj 0.68(0.58–0.80) <.0001 0.69(0.52–0.92) 0.0103 0.91(0.65–1.28) 0.5823 1.18(0.71–1.96) 0.5207 0.81(0.56–1.19) 0.2878 0.70(0.52–0.93) 0.0131 0.86(0.72–1.02) 0.0889 1.15(0.98–1.34) 0.0853
Higher-secondary Unadj 0.91(0.78–1.07) 0.2391 0.80(0.59–1.08) 0.1492 2.75(2.00–3.78) <.0001 3.64(2.24–5.92) <.0001 0.70(0.47–1.06) 0.0932 0.89(0.65–1.21) 0.4473 1.17(0.97–1.41) 0.0975 1.86(1.60–2.16) <.0001
Adj 0.57(0.47–0.70) <.0001 0.60(0.41–0.88) 0.0084 0.83(0.56–1.23) 0.3516 1.14(0.65–2.01) 0.6514 0.69(0.41–1.16) 0.1596 0.61(0.42–0.88) 0.0080 1.06(0.84–1.35) 0.6239 1.41(1.16–1.72) 0.0007
Graduation and above Unadj 1.00(0.86–1.16) 0.9991 0.80(0.60–1.06) 0.1225 5.18(3.88–6.93) <.0001 6.36(4.04–10.00) <.0001 0.45(0.29–0.71) 0.0005 0.96(0.72–1.28) 0.7988 1.14(0.95–1.37) 0.1683 2.78(2.42–3.19) <.0001
Adj 0.57(0.46–0.70) <.0001 0.54(0.36–0.81) 0.0030 1.08(0.73–1.58) 0.7081 1.47(0.84–2.58) 0.1791 0.48(0.26–0.87) 0.0162 0.64(0.44–0.94) 0.0227 0.95(0.74–1.22) 0.6801 1.54(1.26–1.88) <.0001
Occupational type (Ref = Sedentary) Moderate worker Unadj 4.24(3.78–4.74) <.0001 1.13(0.93–1.38) 0.2099 1.97(1.69–2.31) <.0001 2.67(2.11–3.39) <.0001 6.45(4.67–8.91) <.0001 3.14(2.53–3.89) <.0001 1.90(1.67–2.16) <.0001 1.64(1.49–1.80) <.0001
Adj 1.61(1.39–1.87) <.0001 0.78(0.60–1.00) 0.0525 0.81(0.66–0.99) 0.0349 1.27(0.95–1.69) 0.1063 1.26(0.81–1.96) 0.2978 0.91(0.70–1.19) 0.5019 0.87(0.72–1.05) 0.1416 0.90(0.78–1.04) 0.1514
Hard Worker Unadj 2.75(2.44–3.11) <.0001 1.00(0.82–1.23) 0.9855 0.72(0.59–0.89) 0.0026 1.43(1.08–1.88) 0.0112 3.43(2.42–4.87) <.0001 1.96(1.54–2.48) <.0001 1.84(1.61–2.10) <.0001 1.14(1.03–1.27) 0.0105
Adj 1.45(1.24–1.71) <.0001 0.53(0.40–0.69) <.0001 0.60(0.46–0.77) 0.0001 0.84(0.60–1.17) 0.3041 1.89(1.17–3.04) 0.0089 0.90(0.66–1.21) 0.4701 0.78(0.64–0.95) 0.0151 0.78(0.67–0.91) 0.0017
Residential area (Ref = Urban) Rural Unadj 0.68(0.63–0.74) <.0001 0.77(0.66–0.91) 0.0020 0.25(0.21–0.29) <.0001 0.37(0.31–0.46) <.0001 0.85(0.69–1.05) 0.1382 1.10(0.92–1.31) 0.2958 1.35(1.21–1.50) <.0001 0.62(0.57–0.67) <.0001
Adj 0.95(0.85–1.07) 0.3945 0.86(0.67–1.10) 0.2187 0.54(0.43–0.67) <.0001 0.92(0.69–1.22) 0.5461 0.88(0.66–1.18) 0.3886 1.47(1.15–1.87) 0.0019 1.39(1.19–1.63) <.0001 0.87(0.77–0.98) 0.0231
Water source (Ref = Unsafe) May be unsafe Unadj 1.98(1.47–2.67) <.0001 1.05(0.67–1.65) 0.8233 4.21(1.88–9.42) 0.0005 4.44(1.42–13.85) 0.0103 1.31(0.70–2.47) 0.4003 1.54(0.88–2.67) 0.1288 1.74(1.21–2.51) 0.0028 0.89(0.72–1.11) 0.2944
Adj 1.59(1.17–2.16) 0.0032 0.83(0.52–1.33) 0.4374 2.10(0.92–4.81) 0.0780 2.89(0.91–9.18) 0.0714 1.28(0.67–2.45) 0.4587 1.58(0.89–2.80) 0.1213 1.75(1.19–2.58) 0.0045 0.83(0.64–1.07) 0.1451
Safe Unadj 2.19(1.56–3.07) <.0001 1.21(0.70–2.09) 0.5014 14.69(6.46–33.39) <.0001 13.27(4.15–42.39) <.0001 1.04(0.47–2.31) 0.9152 1.51(0.78–2.90) 0.2208 1.05(0.66–1.69) 0.8252 2.11(1.64–2.73) <.0001
Adj 1.39(0.97–1.99) 0.0743 0.84(0.46–1.54) 0.5705 2.59(1.10–6.12) 0.0297 3.52(1.06–11.64) 0.0396 1.27(0.55–2.95) 0.5745 1.50(0.74–3.04) 0.2620 1.08(0.65–1.80) 0.7595 1.16(0.84–1.58) 0.3729
Sanitation level regarding toilet use (Ref = Poor) Average Unadj 1.18(1.06–1.32) 0.0025 1.10(0.89–1.35) 0.3709 2.37(1.79–3.14) <.0001 2.46(1.64–3.67) <.0001 0.79(0.62–1.01) 0.0585 1.10(0.89–1.36) 0.3819 1.07(0.95–1.21) 0.2722 1.13(1.02–1.24) 0.0158
Adj 1.12(0.99–1.26) 0.0766 1.11(0.87–1.42) 0.4098 1.40(1.02–1.91) 0.0375 1.74(1.13–2.66) 0.0116 0.84(0.63–1.12) 0.2294 1.16(0.91–1.48) 0.2219 1.07(0.93–1.24) 0.3302 0.92(0.81–1.04) 0.1827
Good Unadj 1.57(1.41–1.76) <.0001 1.20(0.97–1.49) 0.0919 6.95(5.33–9.06) <.0001 7.53(5.15–11.00) <.0001 0.74(0.57–0.97) 0.0296 1.23(0.98–1.53) 0.0752 1.23(1.08–1.41) 0.0018 2.14(1.94–2.36) <.0001
Adj 1.34(1.15–1.55) 0.0001 1.10(0.81–1.49) 0.5611 2.07(1.47–2.92) <.0001 3.73(2.37–5.86) <.0001 0.74(0.52–1.06) 0.1024 1.38(1.02–1.85) 0.0362 1.52(1.27–1.83) <.0001 1.38(1.19–1.61) <.0001
Socio-economic status (Ref = Very poor) Poor Unadj 1.21(1.07–1.37) 0.0027 1.03(0.82–1.31) 0.7839 2.12(1.64–2.74) <.0001 1.85(1.28–2.66) 0.0010 0.95(0.72–1.25) 0.7015 1.04(0.80–1.36) 0.7708 1.14(0.97–1.33) 0.1067 1.16(1.04–1.30) 0.0079
Adj 1.06(0.93–1.22) 0.3688 1.00(0.76–1.31) 0.9817 1.11(0.84–1.48) 0.4590 0.93(0.63–1.37) 0.7206 1.07(0.79–1.44) 0.6692 1.00(0.75–1.33) 0.9980 1.19(1.00–1.42) 0.0523 0.96(0.83–1.10) 0.5194
Lower middle Unadj 1.14(1.00–1.31) 0.0572 0.88(0.67–1.15) 0.3441 2.40(1.84–3.14) <.0001 2.43(1.68–3.52) <.0001 0.81(0.59–1.12) 0.1993 0.96(0.72–1.30) 0.8016 1.19(1.00–1.42) 0.0461 1.46(1.29–1.65) <.0001
Adj 1.04(0.90–1.20) 0.6175 0.86(0.63–1.17) 0.3356 1.08(0.80–1.47) 0.6145 1.03(0.69–1.53) 0.8912 0.97(0.69–1.37) 0.8702 0.89(0.65–1.23) 0.4732 1.25(1.03–1.52) 0.0265 1.16(1.00–1.35) 0.0515
Upper middle Unadj 1.02(0.90–1.16) 0.7501 0.92(0.72–1.18) 0.5314 2.35(1.82–3.04) <.0001 2.44(1.71–3.48) <.0001 0.52(0.37–0.72) 0.0001 1.24(0.95–1.61) 0.1123 1.39(1.18–1.63) <.0001 1.57(1.40–1.76) <.0001
Adj 0.98(0.85–1.14) 0.8120 1.00(0.75–1.34) 0.9983 1.02(0.75–1.39) 0.8935 0.97(0.65–1.44) 0.8610 0.64(0.44–0.92) 0.0152 1.09(0.82–1.46) 0.5535 1.35(1.12–1.62) 0.0015 1.24(1.08–1.44) 0.0033
Upper Unadj 0.97(0.85–1.11) 0.6451 0.78(0.60–1.01) 0.0634 1.68(1.28–2.21) 0.0002 1.80(1.24–2.61) 0.0021 0.47(0.33–0.67) <.0001 1.24(0.95–1.61) 0.1109 2.15(1.85–2.50) <.0001 1.31(1.16–1.48) <.0001
Adj 1.07(0.92–1.25) 0.3873 0.91(0.67–1.25) 0.5742 1.19(0.86–1.65) 0.2921 0.97(0.64–1.48) 0.8933 0.59(0.40–0.88) 0.0084 1.11(0.82–1.51) 0.4986 2.16(1.80–2.59) <.0001 1.33(1.14–1.56) 0.0003

COPD = Chronic obstructive pulmonary disease; OR = Odds ratio; 95% CI = 95% confidence interval; ‘-‘ Refer to situation where valid estimate for the Odds Ratio could not be determined owing to insufficient cell values.

Table 4. Association (both unadjusted and adjusted) of socio-demographic characteristics with self-perceived specific communicable morbidities, type of ailments and respective care-seeking pattern among recruited residents of Malda, West Bengal, India (N = 43999).

Socio-demographics Categories Measurement (Unadj = Bivariate Adj = Multivariate) Suffering from specific communicable ailments (Based on last 3 episodes of ill-health) Type of Self-perceived morbidity (most recent) Care sought from (Ref = Non-qualified)
Gastroenteritis Typhoid Respiratory tract infection Skin infections and related disorders Communicable diseases (Ref = Non-communicable) Qualified, private sector practitioner Qualified, Govt. sector practitioner
OR (95%CI) p value OR (95%CI) p value OR (95%CI) p value OR (95%CI) p value OR (95%CI) p value OR (95%CI) p value OR (95%CI) p value
Age group of the subject (Ref = <18–40years) <5 years Unadj 6.14(5.38–7.00) <.0001 1.03(0.62–1.72) 0.9036 5.32(4.89–5.79) <.0001 2.30(1.87–2.84) <.0001 9.83(8.65–11.17) <.0001 1.19(1.09–1.31) 0.0002 0.76(0.65–0.89) 0.0005
Adj - - - - - - - - - - - - - -
5–<18 years Unadj 1.36(1.21–1.54) <.0001 0.81(0.60–1.09) 0.1647 1.40(1.31–1.50) <.0001 1.37(1.19–1.59) <.0001 3.28(3.05–3.54) <.0001 0.76(0.71–0.83) <.0001 0.99(0.89–1.10) 0.8215
Adj 1.07(0.87–1.32) 0.5394 0.73(0.44–1.20) 0.2141 1.13(1.01–1.27) 0.0357 0.95(0.74–1.21) 0.6772 2.51(2.22–2.83) <.0001 0.69(0.60–0.78) <.0001 0.80(0.68–0.95) 0.0112
41–60 years Unadj 1.52(1.32–1.76) <.0001 1.07(0.76–1.52) 0.6862 1.41(1.30–1.54) <.0001 1.20(1.00–1.45) 0.0559 0.57(0.53–0.61) <.0001 1.36(1.26–1.46) <.0001 1.35(1.22–1.49) <.0001
Adj 1.50(1.29–1.75) <.0001 1.17(0.81–1.70) 0.3968 1.49(1.36–1.62) <.0001 1.27(1.04–1.55) 0.0190 0.59(0.55–0.64) <.0001 1.31(1.21–1.41) <.0001 1.29(1.16–1.44) <.0001
>60 years Unadj 2.46(1.98–3.06) <.0001 0.43(0.16–1.18) 0.1015 1.72(1.49–1.99) <.0001 1.19(0.84–1.70) 0.3286 0.43(0.38–0.48) <.0001 1.78(1.59–1.99) <.0001 1.68(1.44–1.96) <.0001
Adj 2.44(1.92–3.11) <.0001 0.51(0.18–1.43) 0.2016 1.82(1.56–2.13) <.0001 1.13(0.77–1.65) 0.5323 0.44(0.39–0.50) <.0001 1.56(1.38–1.78) <.0001 1.43(1.20–1.69) <.0001
Gender (Ref = Male) Female Unadj 1.00(0.91–1.09) 0.9256 1.05(0.82–1.34) 0.7115 1.02(0.97–1.08) 0.4132 1.08(0.96–1.22) 0.2088 0.70(0.66–0.73) <.0001 0.95(0.90–1.00) 0.0533 0.85(0.79–0.92) <.0001
Adj 1.06(0.93–1.20) 0.3977 1.02(0.76–1.38) 0.8893 1.04(0.97–1.11) 0.2976 1.11(0.95–1.29) 0.1787 0.72(0.67–0.77) <.0001 0.95(0.88–1.02) 0.1523 0.80(0.73–0.88) <.0001
Religion (Ref = Hindu) Muslim Unadj 1.13(1.03–1.25) 0.0105 1.63(1.27–2.09) 0.0001 1.04(0.98–1.10) 0.1694 1.51(1.33–1.71) <.0001 1.44(1.36–1.52) <.0001 0.83(0.78–0.88) <.0001 0.97(0.90–1.06) 0.5222
Adj 0.86(0.74–0.99) 0.0339 1.80(1.31–2.46) 0.0003 1.01(0.93–1.10) 0.8205 1.25(1.06–1.49) 0.0089 1.18(1.09–1.28) <.0001 0.85(0.69–0.76) 0.0008 0.92(0.87–0.96) <.0001
Others Unadj 0.93(0.41–2.12) 0.8552 - - 1.41(0.95–2.11) 0.0917 1.59(0.65–3.93) 0.3110 1.39(0.92–2.12) 0.1203 0.58(0.35–0.95) 0.0304 1.03(0.57–1.85) 0.9272
Adj 0.76(0.28–2.08) 0.5918 - - 1.21(0.73–2.00) 0.4602 1.32(0.48–3.64) 0.5892 0.91(0.56–1.49) 0.7080 0.77(0.44–1.35) 0.3569 1.41(0.75–2.65) 0.2819
Caste (Ref = General) SC/ST/OBC Unadj 1.03(0.94–1.13) 0.5205 1.59(1.22–2.08) 0.0006 1.05(1.00–1.11) 0.0669 0.83(0.73–0.94) 0.0028 1.12(1.06–1.17) <.0001 0.83(0.79–0.88) <.0001 1.11(1.02–1.20) 0.0136
Adj 0.88(0.77–1.00) 0.0500 1.93(1.40–2.67) <.0001 1.06(0.98–1.14) 0.1372 0.87(0.75–1.02) 0.0866 1.15(1.08–1.24) <.0001 0.97(0.90–1.04) 0.3718 0.93(0.91–0.96) <.0001
Education level of the subject (Ref = Illiterate) Primary Unadj 0.79(0.69–0.90) 0.0005 0.91(0.64–1.30) 0.6172 0.86(0.80–0.94) 0.0004 1.06(0.89–1.27) 0.5146 1.67(1.56–1.80) <.0001 1.04(0.96–1.13) 0.2992 0.90(0.82–1.00) 0.0534
Adj 1.05(0.89–1.24) 0.5975 1.04(0.68–1.58) 0.8734 1.04(0.94–1.14) 0.4901 1.08(0.87–1.34) 0.4960 1.04(0.95–1.14) 0.4108 1.10(1.00–1.22) 0.0461 0.95(0.84–1.07) 0.4017
Secondary Unadj 0.55(0.48–0.63) <.0001 0.95(0.67–1.35) 0.7802 0.75(0.69–0.81) <.0001 1.02(0.85–1.21) 0.8723 1.23(1.14–1.32) <.0001 1.64(1.52–1.77) <.0001 0.91(0.82–1.01) 0.0617
Adj 0.86(0.71–1.03) 0.0960 1.19(0.77–1.83) 0.4408 1.02(0.92–1.13) 0.6868 1.20(0.96–1.51) 0.1082 0.97(0.88–1.07) 0.5397 1.30(1.18–1.44) <.0001 0.91(0.80–1.04) 0.1501
Higher-secondary Unadj 0.38(0.27–0.52) <.0001 0.77(0.40–1.47) 0.4233 0.69(0.60–0.81) <.0001 0.78(0.56–1.10) 0.1535 1.08(0.94–1.24) 0.2725 2.48(2.14–2.86) <.0001 1.17(0.95–1.44) 0.1500
Adj 0.78(0.54–1.13) 0.1876 1.20(0.54–2.68) 0.6505 1.21(1.01–1.46) 0.0440 0.90(0.60–1.35) 0.6090 1.12(0.94–1.34) 0.2057 1.42(1.19–1.69) 0.0001 1.02(0.79–1.31) 0.8865
Graduation and above Unadj 0.40(0.29–0.56) <.0001 0.86(0.45–1.65) 0.6540 0.65(0.55–0.76) <.0001 0.44(0.28–0.69) 0.0004 1.00(0.86–1.16) 0.9940 3.39(2.91–3.95) <.0001 0.73(0.55–0.97) 0.0302
Adj 0.92(0.61–1.41) 0.7084 1.46(0.59–3.59) 0.4109 1.37(1.10–1.71) 0.0054 0.69(0.40–1.21) 0.1973 1.38(1.13–1.69) 0.0020 1.30(1.06–1.59) 0.0104 0.60(0.43–0.85) 0.0036
Maximum educational level among adult household members (Ref = Illiterate) Primary Unadj 0.81(0.71–0.93) 0.0028 1.10(0.72–1.69) 0.6518 0.90(0.83–0.98) 0.0153 0.95(0.78–1.15) 0.6103 0.95(0.87–1.03) 0.2020 1.27(1.15–1.41) <.0001 0.99(0.87–1.11) 0.8128
Adj 0.78(0.66–0.93) 0.0058 1.18(0.72–1.92) 0.5109 0.85(0.76–0.95) 0.0028 1.02(0.81–1.28) 0.8682 0.92(0.83–1.02) 0.1274 1.07(0.95–1.21) 0.2432 0.97(0.85–1.12) 0.7155
Secondary Unadj 0.64(0.57–0.72) <.0001 1.22(0.83–1.78) 0.3092 0.83(0.77–0.90) <.0001 0.83(0.70–0.99) 0.0368 0.80(0.74–0.86) <.0001 1.94(1.78–2.12) <.0001 1.04(0.93–1.16) 0.4663
Adj 0.73(0.62–0.87) 0.0003 1.40(0.87–2.24) 0.1621 0.83(0.75–0.93) 0.0006 0.95(0.76–1.20) 0.6828 0.95(0.86–1.05) 0.3480 1.26(1.13–1.41) <.0001 1.03(0.90–1.18) 0.6971
Higher-secondary Unadj 0.42(0.35–0.51) <.0001 0.82(0.49–1.39) 0.4670 0.65(0.59–0.73) <.0001 0.86(0.68–1.08) 0.1891 0.57(0.51–0.63) <.0001 2.80(2.50–3.13) <.0001 1.21(1.04–1.40) 0.0138
Adj 0.56(0.43–0.72) <.0001 1.03(0.53–1.97) 0.9378 0.71(0.62–0.83) <.0001 1.16(0.87–1.55) 0.3232 0.84(0.73–0.96) 0.0097 1.40(1.22–1.62) <.0001 1.05(0.87–1.27) 0.5874
Graduation and above Unadj 0.40(0.33–0.48) <.0001 0.89(0.54–1.45) 0.6352 0.54(0.49–0.60) <.0001 0.50(0.38–0.64) <.0001 0.44(0.40–0.48) <.0001 4.56(4.10–5.07) <.0001 1.09(0.93–1.28) 0.2749
Adj 0.56(0.42–0.73) <.0001 1.15(0.58–2.28) 0.6840 0.62(0.53–0.73) <.0001 0.80(0.57–1.12) 0.1948 0.71(0.62–0.83) <.0001 1.91(1.65–2.22) <.0001 1.00(0.81–1.23) 0.9857
Occupational type (Ref = Sedentary) Moderate worker Unadj 0.91(0.80–1.03) 0.1237 1.15(0.84–1.57) 0.3931 0.83(0.77–0.89) <.0001 0.76(0.64–0.88) 0.0005 0.35(0.33–0.38) <.0001 1.12(1.04–1.20) 0.0015 0.97(0.88–1.07) 0.5283
Adj 1.04(0.86–1.27) 0.6855 1.03(0.64–1.66) 0.9090 0.99(0.89–1.11) 0.8661 0.73(0.58–0.93) 0.0114 0.84(0.76–0.94) 0.0016 0.89(0.80–0.99) 0.0304 0.79(0.68–0.92) 0.0020
Hard Worker Unadj 1.05(0.92–1.18) 0.4784 1.37(1.01–1.86) 0.0447 0.93(0.86–1.00) 0.0372 0.87(0.74–1.02) 0.0782 0.58(0.54–0.62) <.0001 0.74(0.68–0.79) <.0001 0.91(0.82–1.01) 0.0681
Adj 1.03(0.84–1.26) 0.7789 0.96(0.59–1.54) 0.8578 1.04(0.93–1.16) 0.5490 0.75(0.59–0.96) 0.0197 0.94(0.85–1.05) 0.3062 0.72(0.64–0.81) <.0001 0.69(0.59–0.81) <.0001
Residential area (Ref = Urban) Rural Unadj 1.80(1.62–2.00) <.0001 2.97(2.14–4.12) <.0001 1.22(1.15–1.29) <.0001 1.67(1.45–1.91) <.0001 1.91(1.81–2.01) <.0001 0.53(0.5–0.56) <.0001 0.71(0.66–0.77) <.0001
Adj 1.76(1.50–2.07) <.0001 2.85(1.86–4.38) <.0001 1.27(1.16–1.38) <.0001 1.45(1.19–1.77) 0.0002 1.47(1.36–1.60) <.0001 0.82(0.75–0.89) <.0001 0.72(0.64–0.81) <.0001
Water source (Ref = Unsafe) May be unsafe Unadj 0.85(0.68–1.07) 0.1697 0.6(0.36–1.02) 0.0578 1.16(1.00–1.35) 0.0511 0.99(0.71–1.37) 0.9488 0.96(0.83–1.11) 0.5619 1.08(0.92–1.27) 0.3678 0.89(0.72–1.10) 0.2944
Adj 0.88(0.67–1.14) 0.3298 0.89(0.51–1.55) 0.6809 1.29(1.07–1.54) 0.0066 1.21(0.83–1.77) 0.3139 1.25(1.05–1.47) 0.0101 0.87(0.72–1.04) 0.1214 0.87(0.69–1.09) 0.2283
Safe Unadj 0.53(0.38–0.73) 0.0002 0.31(0.12–0.75) 0.0097 0.77(0.63–0.94) 0.0102 0.57(0.36–0.91) 0.0179 0.52(0.43–0.62) <.0001 3.47(2.84–4.23) <.0001 1.32(0.99–1.75) 0.0597
Adj 0.85(0.56–1.30) 0.4555 0.77(0.26–2.26) 0.6310 1.04(0.81–1.34) 0.7630 1.13(0.66–1.93) 0.6614 1.12(0.89–1.40) 0.3228 1.33(1.05–1.67) 0.0173 1.04(0.75–1.43) 0.8285
Sanitation level regarding toilet use (Ref = Poor) Average Unadj 0.78(0.70–0.86) <.0001 0.93(0.70–1.22) 0.5857 0.91(0.86–0.97) 0.0053 0.76(0.66–0.87) 0.0001 0.79(0.74–0.84) <.0001 1.67(1.55–1.79) <.0001 1.17(1.06–1.28) 0.0011
Adj 1.17(1.02–1.34) 0.0253 1.12(0.81–1.54) 0.4905 1.07(0.99–1.16) 0.1089 0.91(0.77–1.07) 0.2523 1.01(0.93–1.09) 0.8903 1.17(1.07–1.28) 0.0004 1.06(0.95–1.18) 0.3021
Good Unadj 0.51(0.45–0.57) <.0001 0.45(0.31–0.65) <.0001 0.75(0.70–0.81) <.0001 0.57(0.48–0.67) <.0001 0.47(0.44–0.51) <.0001 3.12(2.90–3.37) <.0001 1.22(1.10–1.36) 0.0002
Adj 0.99(0.82–1.19) 0.8963 0.81(0.50–1.29) 0.3664 0.97(0.87–1.08) 0.5920 0.87(0.69–1.09) 0.2259 0.78(0.70–0.86) <.0001 1.58(1.42–1.75) <.0001 0.94(0.81–1.08) 0.3918
Socio-economic status (Ref = Very poor) Poor Unadj 0.76(0.66–0.86) <.0001 0.90(0.62–1.32) 0.5869 0.86(0.80–0.93) 0.0001 0.71(0.59–0.85) 0.0002 0.77(0.71–0.83) <.0001 1.76(1.61–1.91) <.0001 1.18(1.06–1.32) 0.0025
Adj 0.94(0.79–1.10) 0.4221 1.01(0.67–1.55) 0.9472 0.97(0.88–1.06) 0.5003 0.82(0.66–1.00) 0.0548 0.98(0.90–1.07) 0.6521 1.23(1.11–1.36) <.0001 1.14(1.01–1.28) 0.0421
Lower middle Unadj 0.65(0.56–0.76) <.0001 0.98(0.65–1.47) 0.9040 0.75(0.69–0.82) <.0001 0.67(0.54–0.82) <.0001 0.73(0.67–0.79) <.0001 2.08(1.90–2.28) <.0001 1.11(0.98–1.25) 0.1190
Adj 0.79(0.65–0.95) 0.0142 1.17(0.76–1.81) 0.4706 0.85(0.77–0.94) 0.0024 0.78(0.62–0.98) 0.0296 0.95(0.86–1.05) 0.3006 1.41(1.26–1.57) <.0001 1.11(0.97–1.28) 0.1424
Upper middle Unadj 0.73(0.64–0.84) <.0001 1.00(0.69–1.46) 0.9973 0.67(0.62–0.73) <.0001 0.68(0.56–0.81) <.0001 0.78(0.72–0.85) <.0001 2.28(2.09–2.49) <.0001 0.99(0.87–1.11) 0.8234
Adj 0.85(0.72–1.01) 0.0657 0.96(0.64–1.46) 0.8612 0.73(0.66–0.81) <.0001 0.73(0.59–0.91) 0.0044 0.95(0.86–1.05) 0.3002 1.59(1.43–1.77) <.0001 1.06(0.92–1.21) 0.4332
Upper Unadj 0.71(0.62–0.81) <.0001 0.92(0.63–1.36) 0.6827 0.63(0.58–0.68) <.0001 0.79(0.66–0.94) 0.0091 0.86(0.79–0.93) 0.0001 1.85(1.69–2.03) <.0001 0.99(0.88–1.12) 0.9137
Adj 0.72(0.60–0.86) 0.0004 0.63(0.41–0.99) 0.0445 0.63(0.56–0.70) <.0001 0.79(0.64–0.98) 0.0304 0.84(0.75–0.92) 0.0005 1.51(1.35–1.69) <.0001 1.08(0.93–1.25) 0.3061

OR = Odds ratio; 95% CI = 95% confidence interval; ‘-‘ Refer to situation where valid estimate for the Odds Ratio could not be determined owing to insufficient cell values.

Compared to males, females had higher odds of suffering from APD [AOR = 1.60(1.45–1.77)], HTN [AOR = 1.53(1.28–1.83)], anemia [AOR = 16.26(10.75–24.59)] and OA [AOR = 2.58(2.07–3.22)] and lower odds for COPD [AOR = 0.59(0.48–0.73)] and DM [AOR = 0.73(0.57–0.92)]. Muslims suffered less from APD [AOR = 0.77(0.69–0.87)] and gastroenteritis [AOR = 0.86(0.74–0.99)] but more from DM [AOR = 1.40(1.06–1.85)], typhoid [AOR = 1.80(1.31–2.46)] and skin infections [AOR = 1.25(1.06–1.49)] than Hindus. With reference to general, backward castes suffered less from APD [AOR = 0.74(0.67–0.81)], HTN [AOR = 0.82(0.69–0.97)] and anemia [AOR = 0.77(0.60–0.98)] but more from typhoid [AOR = 1.93(1.40–2.67)].

Compared to illiterates, higher familial education was associated with lower likelihood of APD [AORHigher Secondary = 0.57(0.47–0.70), AOR≥Graduation = 0.57(0.46–0.70)], COPD [AORHigher Secondary = 0.60(0.41–0.88), AOR≥Graduation = 0.54(0.36–0.81)], anemia [AOR≥Graduation = 0.48(0.26–0.87)], OA [AORHigher Secondary = 0.61(0.42–0.88), AOR≥Graduation = 0.64(0.44–0.94)], gastroenteritis [AORHigher Secondary = 0.56(0.43–0.72), AOR≥Graduation = 0.56(0.42–0.73)] and RTI [AORHigher Secondary = 0.71(0.62–0.83), AOR≥Graduation = 0.62(0.53–0.73)].

Hard workers (reference = Sedentary) were more prone to APD [AOR = 1.45(1.24–1.71)] and anemia [AOR = 1.89(1.17–3.04)] but less vulnerable to COPD [AOR = 0.53(0.40–0.69)] and HTN [AOR = 0.60(0.46–0.77)]. Rural residents, compared to urban, were less likely to have HTN [AOR = 0.54(0.43–0.67)] but more prone to OA [AOR = 1.47(1.15–1.87)], gastroenteritis [AOR = 1.76(1.50–2.07)], typhoid [AOR = 2.85(1.86–4.38)], RTI [AOR = 1.27(1.16–1.38)] and skin infection [AOR = 1.45(1.19–1.77)].

Drinking safer water and practicing better sanitation regarding toilet use seemed to be associated with lower likelihood of suffering from gastroenteritis, typhoid, RTI and skin infections in bivariate analyses but the multivariate analyses lacked power. Relatively higher SES was associated with lower likelihood of anemia [AORUpper middle = 0.64(0.44–0.92), AORUpper = 0.59(0.40–0.88)], gastroenteritis [AORUpper = 0.72(0.60–0.86)], typhoid [AORUpper = 0.63(0.41–0.99)], RTI [AORUpper middle = 0.73(0.66–0.81), AORUpper = 0.63(0.56–0.70)] and skin infections [AORUpper middle = 0.73(0.59–0.91), AORUpper = 0.79(0.64–0.98)]. Higher SES also seemed to be associated with higher odds of having HTN [ORUpper middle = 2.35(1.82–3.04), ORUpper = 1.68(1.28–2.21)] and DM [ORUpper middle = 2.44(1.71–3.48), ORUpper = 1.80(1.24–2.61)]. (Tables 3 and 4)

In comparison with respective reference groups, perceived severity of the ailments increased with higher age [for severe disease, AOR41–60 years = 2.34(2.10–2.61), AOR>60 years = 4.25(3.61–5.00)], familial education [for severe disease, AORHigher secondary = 1.41(1.16–1.72), AOR>Graduation = 1.54(1.26–1.88)], sanitation level regarding toilet use practices [for severe disease, AORGood = 1.38(1.19–1.61)] and SES [for severe disease, AORUpper middle = 1.24(1.08–1.44), AORUpper = 1.33(1.14–1.56)]. Perception of severity was lower among hard-workers [for severe disease, AOR = 0.78(0.67–0.91)] and rural residents [for severe disease, AOR = 0.87(0.77–0.98)]. (Table 3)

With respect to 18–40 year old, younger persons were more likely [AOR5–18 = 2.51(2.22–2.83)], and older residents were less likely [AOR41–60 = 0.59(0.55–0.64), AOR>60 = 0.44(0.39–0.50)] to suffer from communicable diseases (reference = NCD). Compared to respective reference groups, females [AOR = 0.72(0.67–0.77)], residents having higher familial education [AOR = 0.71(0.62–0.83)] and higher SES [AOR = 0.84(0.75–0.92)] had lower likelihood of communicable diseases. Muslims [AOR = 1.18(1.09–1.28)], persons belonging to backward [AOR = 1.15(1.08–1.24)] caste, those who had higher individual education [AOR≥Graduation = 1.38(1.13–1.69)] and rural [AOR = 1.47(1.36–1.60)] residents suffered more from communicable diseases. (Table 4)

With reference to respective comparison groups, subjects aged 5–18 years [AORPrivate = 0.69(0.60–0.78), AORGovt = 0.80(0.68–0.95)], females [AORGovt = 0.80(0.73–0.88)], Muslim religion [AORPrivate = 0.85(0.69–0.76), ORGovt = 0.92(0.87–0.96)], backward caste [AORGovt = 0.93(0.91–0.96)], physically demanding occupation [for hard work, AORPrivate = 0.72(0.64–0.81), AORGovt = 0.69(0.59–0.81)] and rural residence [AORPrivate = 0.82(0.75–0.89), AORGovt = 0.72(0.64–0.81)] were associated with lower likelihood of visiting qualified practitioners (reference = Non-qualified). Age > 40 years [for 41–60 years age group: AORPrivate = 1.31(1.21–1.41), AORGovt = 1.29(1.16–1.44); for age > 60 years: AORPrivate = 1.56(1.38–1.78), AORGovt = 1.43(1.20–1.69)], higher individual [for higher secondary: AORPrivate = 1.42(1.19–1.69) and for ≥ Graduation: AORPrivate = 1.30(1.06–1.59)] and familial education [for higher secondary: AORPrivate = 1.26(1.13–1.41) and for ≥ Graduation: AORPrivate = 1.40(1.22–1.62)], better sanitary practices [for average practice: AORPrivate = 1.17(1.07–1.28) and for good practice: AORPrivate = 1.58(1.42–1.75)] and higher SES [for Upper middle: AORPrivate = 1.59(1.43–1.77) and for Upper: AORPrivate = 1.51(1.35–1.69)] were associated with higher odds of seeking care from qualified (reference = Non-qualified) practitioners. (Table 4)

Likelihood of visiting qualified practitioners were lower among subjects who suffered from APD [AORPrivate = 0.41(0.37–0.46), AORGovt = 0.36(0.31–0.43)], OA [AORPrivate = 0.72(0.59–0.88), AORGovt = 0.58(0.43–0.78)], gastroenteritis [AORPrivate = 0.28(0.24–0.33), AORGovt = 0.69(0.58–0.81)], RTI [AORPrivate = 0.35(0.32–0.39), AORGovt = 0.46(0.41–0.52)], skin infections [AORPrivate = 0.65(0.55–0.77)]. Those who had COPD [AORPrivate = 1.80(1.46–2.23), AORGovt = 1.78(1.38–2.31)], HTN [AORPrivate = 1.94(1.60–2. 36), AORGovt = 1.37(1.05–1.79)], DM [AORPrivate = 4.94(3.55–6.87), AORGovt = 3.28(2.20–4.91)], typhoid [AORPrivate = 2.86(2.04–4.03), AORGovt = 3.95(2.70–5.79)]and NCDs [AORPrivate = 2.31(2.16–2.48), AORGovt = 1.30(1.18–1.42)] were more likely to visit qualified practitioners. Higher self-perceived disease severity [for moderate: AORPrivate = 1.32(1.16–1.51); for severe: AORPrivate = 3.16(2.86–3.49), AORGovt = 1.95(1.71–2.24)] was also positively associated with visiting qualified practitioners. (Table 5)

Table 5. Association (both unadjusted and adjusted) of self-perceived specific morbidity type, specific ailments and severity with respective care-seeking pattern among recruited residents of Malda, West Bengal, India (N = 43999).

Measurement (Unadj = Bivariate Adj = Multivariate) Care sought from (Ref = Non-qualified)
Qualified, private sector practitioner Qualified, Govt. sector practitioner
OR (95%CI) p value OR (95%CI) p value
Type of Self-perceived morbidity (most recent) Non-communicable diseases (Ref = communicable) Unadj 2.31(2.18–2.45) <.0001 1.48(1.37–1.60) <.0001
Adj 2.31(2.16–2.48) <.0001 1.30(1.18–1.42) <.0001
Suffering from specific non-communicable ailments (Based on last three episodes of ill-health) Acid peptic disorder Unadj 0.47(0.43–0.52) <.0001 0.37(0.32–0.43) <.0001
Adj 0.41(0.37–0.46) <.0001 0.36(0.31–0.43) <.0001
Chronic obstructive pulmonary disease Unadj 1.96(1.62–2.37) <.0001 2.10(1.65–2.66) <.0001
Adj 1.80(1.46–2.23) <.0001 1.78(1.38–2.31) <.0001
Hypertension Unadj 3.24(2.72–3.87) <.0001 1.82(1.42–2.33) <.0001
Adj 1.94(1.60–2.36) <.0001 1.37(1.05–1.79) 0.0202
Diabetes Mellitus Unadj 7.73(5.62–10.64) <.0001 4.24(2.87–6.27) <.0001
Adj 4.94(3.55–6.87) <.0001 3.28(2.20–4.91) <.0001
Anaemia Unadj 0.75(0.59–0.94) 0.0123 0.80(0.58–1.09) 0.1603
Adj 0.84(0.66–1.08) 0.1714 0.94(0.68–1.31) 0.7194
Osteoarthritis Unadj 0.84(0.70–1.01) 0.0641 0.67(0.51–0.88) 0.0047
Adj 0.72(0.59–0.88) 0.0014 0.58(0.43–0.78) 0.0003
Suffering from specific communicable ailments (Based on last 3 episodes of ill-health) Gastroenteritis Unadj 0.33(0.29–0.37) <.0001 0.64(0.56–0.74) <.0001
Adj 0.28(0.24–0.33) <.0001 0.69(0.58–0.81) <.0001
Typhoid Unadj 2.53(1.85–3.45) <.0001 3.48(2.43–4.97) <.0001
Adj 2.86(2.04–4.03) <.0001 3.95(2.70–5.79) <.0001
Respiratory tract infection Unadj 0.43(0.40–0.46) <.0001 0.44(0.40–0.49) <.0001
Adj 0.35(0.32–0.39) <.0001 0.46(0.41–0.52) <.0001
Skin infections and related disorders Unadj 0.63(0.54–0.72) <.0001 0.84(0.70–1.01) 0.0695
Adj 0.65(0.55–0.77) <.0001 0.84(0.69–1.03) 0.1011
Self-perceived severity (Ref = Mild) Moderate Unadj 1.28(1.15–1.44) <.0001 1.14(0.97–1.34) 0.1147
Adj 1.32(1.16–1.51) <.0001 1.10(0.92–1.30) 0.2930
Severe Unadj 3.32(3.06–3.61) <.0001 2.07(1.84–2.34) <.0001
Adj 3.16(2.86–3.49) <.0001 1.95(1.71–2.24) <.0001

OR = Odds ratio; 95% CI = 95% confidence interval

Discussion

The socio-demographic distribution of the recruited population in Malda district was typically identical with a developing world poor-resource setting with potential loopholes in healthcare delivery system. The proportion of underprivileged class, poor education, rural residence, sedentary work, poor access to safe water, poor sanitation and overall lower SES rendered the residents of this district vulnerable to morbidity and poor healthcare-seeking.

More than half (55.91%) of the participants suffered from some recent morbidity while respiratory, gastrointestinal and musculoskeletal diseases were most common. This observed burden of self-perceived morbidity was considerably higher than previously reported values (ranged between 27% and 48%) in similar settings.[2629] Studies conducted in other parts of the globe,[2628] also indicated that respiratory, gastrointestinal and musculoskeletal ailments were perceived commonly.[26,28,30,31] Probably the chronic and disturbing symptoms of these slowly progressive ailments resulted in more attention. Cardio-vascular diseases were generally reported less as we observed.[26] Burden of reported NCDs was marginally higher than communicable diseases.

More than half of the ailments were treated by non-qualified practitioners, which raised a few concerns. Only about 13% visited qualified physicians from Govt. sector. The scenario seemed similar to that of other parts of India, Vietnam and Bangladesh [26,28,32] but a bit different from Afghanistan and Nepal where majority visited Govt. doctors.[33,34] Easy availability, less fees and better responsiveness were probably in favor of visiting non-qualified practitioners. Alike other settings, among subjects visiting non-qualified practitioners, proportion of communicable diseases were higher compared to NCDs while qualified practitioners from private sector treated more NCDs compared to their counterparts from Govt. sector.[3537] The results probably indicated towards the lack of provision to quality healthcare services from Governmental sector in these areas, leading to increased inequality in healthcare-seeking. The resultant high burden of out-of-pocket healthcare costs disproportionately affected the poorer population compelling them towards healthcare-seeking from non-qualified practitioners. NCDs probably were given more importance due to their persistent symptoms and the community was probably less confident about the ability of non-qualified practitioners regarding treatment of these diseases.

Among specific ailments, RTI was perceived to be the commonest, followed by APD, gastroenteritis and skin problem. Contrary to some other study, perceived burden of HTN and DM were found to be relatively lower.[29] May be some of the asymptomatic, mild or currently controlled (on medication) cases were missed.

While more than two third subjects considered their ailments as less severe, those who perceived the severity, visited qualified doctors especially in private sector. The perceived severity probably helped them to overcome the potential barriers (may include: cost, transport, availability and waiting time related issues) in better healthcare-seeking.[28,31,34,35,38,39]

Corroborating with prior observation in similar settings elsewhere, children and adolescents were less likely to suffer from NCDs like APD, COPD, HTN, DM, anemia and OA but more from RTI, gastroenteritis and skin infection.[27,33,35,36,40] As evidenced in previous studies, elderly subjects were more prone to APD, COPD, HTN, DM, OA, gastroenteritis and RTI while among adults, risk of these diseases increased with age.[2629,41,42]

Similar to some previous observation, females had higher likelihood of having APD, anemia and OA but less likely to suffer from COPD and DM [2628] but gender was not found to be associated with communicable diseases.[33,34,36] Muslims suffered less from APD and gastroenteritis but more from DM, typhoid and skin infections. Subjects belonging to SC/ST/OBC castes suffered less from APD, HTN and anemia but more from typhoid. Probably lower awareness and resultant less attention for milder symptoms did influence the patterns of perceived morbidity.

Supporting some prior evidences [27] and contradicting a few,[26,29] our study indicated that higher household education was probably an important predictor for lowering the risk of APD, COPD, anemia, OA, gastroenteritis and RTI while having more education did not individually help the subjects to suffer less except for COPD. Instead regarding HTN, DM and RTI, corroborating available information, higher individual education was associated with increased morbidity.[43] Compared to individual, household education was probably a stronger predictor for healthy practice and proper decision-making regarding care-seeing, together resulting in less morbidity. On the other hand, for subjects with higher education, sedentary work, occupational pressure and better awareness probably increased the perceived burden of HTN, DM, RTI etc.

Occupation with hard work was associated with higher odds of APD and anemia but lower odds of COPD and HTN. Physical exertion, work environment and appropriate nutrition probably were the key factors. Negative association between physical activity and HTN was well-established in prior studies.[42]

Rural residents compared to urban were less prone to HTN (may be due to environmental factors, less anxiety and stress) but they had higher likelihood of having OA, gastroenteritis, typhoid, RTI and skin infection most likely due to lifestyle related factors, less awareness, poor hygiene and inappropriate sanitation. Urban preponderance of HTN was also reported previously [43] although some researchers did not find significant rural/urban variation.[41]

Drinking safer water was associated with higher perceived burden of HTN and DM. Subjects having better sanitary practices regarding toilet use were also suffering more from APD, HTN, DM and OA. Health awareness and knowledge as probably a confounder here that positively influenced both better practices (regarding drinking safe water, toilet use etc.) and improved perception. Reverse causation might also be a possibility (being diagnosed with the disease resulted in better sanitation and hygiene). Drinking safer water and practicing better sanitation regarding toilet use seemed to be also associated with lower likelihood of suffering from gastroenteritis, typhoid, RTI and skin infections.

Alike prior studies, we also found that, residents having comparatively higher SES were less likely to suffer from anemia, gastroenteritis, typhoid, RTI and skin infections [26,29] but seemed to be having higher odds of having HTN and DM.[27,29] While better SES could have improved awareness and in turn better identification of NCDs, means to prevent communicable diseases were also probably better available to them.

Perceived severity of ailments was higher among those with higher age, better familial education, improved sanitation and upper SES and lower among hard-workers and rural residents had. Higher severity of self-perceived morbidity among elderly was also reported previously.[27] Thus perception of severity also seemed to be driven by awareness and knowledge regarding the ailments.

Compared to those aged between 18–40 years, 5–18 years age group were more likely, and older residents were less likely to suffer from communicable diseases than NCDs. Female gender, better familial education and higher SES were negatively associated with risk of communicable diseases. Muslim religion, backward caste, higher individual education and rural residents had higher odds of suffering from communicable diseases.

Socio-demographic predictors of Healthcare-seeking behavior in our study were quite similar to those reported from other parts of the world as well as India with some variations. While elderly subjects commonly visited qualified private and govt. sector physicians,[34] older children, adolescents and females were less likely to be treated by qualified physicians.[38,39] Although in our study compared to Hindus, Muslims visited qualified practitioners less often, in Nepal, religion was not associated with healthcare-seeking.[36] Backward castes, subjects with physically demanding jobs [26] and rural residents also had lower odds of being treated by qualified practitioners.[35,36,40] Subjects having higher individual and familial education,[26,28,33,36] access to better quality of drinking water, better sanitary practices and higher SES were more likely to visit qualified private practitioners.[26,28,32,3436,40,44,45] Thus as a whole it was evident that while healthcare-seeking subjects having weaker socio-demographic and economic position had higher likelihood of visiting non-qualified practitioners while extremes of ages were more often treated by qualified ones. Likelihood of visiting qualified doctors in private sector was positively associated with higher socio-economic position and health consciousness.

Subjects suffering from NCDs were more likely to visit qualified practitioners especially the private sector.[37] Alike some prior evidences, patients of APD, OA, gastroenteritis, RTI and skin infections were less likely to be treated by qualified practitioners.[32,44,45] Subjects suffering from COPD, HTN, DM and typhoid had higher likelihood of visiting qualified practitioners. Probably recurrent, short-lasting ailments were not influential enough to pursue the residents to overcome the barriers of better healthcare-seeking while chronic diseases of incurable nature were.

Self-perceived severity of ailments were positively associated with odds of visiting qualified practitioners more so in private sector and this finding also supported prior evidences.[35,36,40] The perception that more severe diseases were worth paying more attention, time and money and thus visiting qualified doctors especially in the private sector probably was reflected here.

Despite efficient sampling design, use of detailed questionnaire and robust analyses, our study had certain limitations. Like any other cross-sectional study, causal interpretation of the observed associations is not recommended. Due to the potential vulnerability to temporal ambiguity by design, some of our observations might have suffered from reverse causation. Although self-perceived morbidity and severity are currently being considered an efficient parameter for the estimation of health needs in communities worldwide, keeping the lower literacy and potential lack of awareness in mind, the reported self-perceived morbidity pattern should only be interpreted as perceived health need of the community, not the prevalence. Residual confounding due to variables not included in our analyses could also be an issue. Information bias due to misclassification of self-reported information should always be kept in mind, especially due to the potential for differential recall. But we do not consider those to be serious issues here because we only dealt with the recent ailments, hence recall period was short and in majority of cases, medical records were consulted. Although results of our study should be extrapolated beyond the study sample with caution, still we are not worried about the generalizability of our results due to the representative nature of our study sample and very low (<8%) non-response.

Conclusion

In this poor-resource setting, most important predictor for healthcare-seeking was the perception regarding severity and nature of ailments, while age, gender, caste, religion, familial education, SES, residential area, sanitation and hygiene influenced the morbidity pattern and relevant healthcare-seeking. Keeping the high burden of self-perceived morbidity in mind, interventions to improve physical health, awareness and care-seeking practices targeting children, elderly, females, backward castes, minority groups, illiterates, rural residents and those having lower SES, poor sanitary practices and inadequate access to safe drinking water were required urgently. Simultaneously, efforts to improve the healthcare service delivery might consider implementation of intervention targeting improvement of knowledge and practice among non-qualified practitioners in poor-resource settings where seeking healthcare services from these practitioners seemed to be a common occurrence.

Acknowledgments

Authors express their deep gratitude to Professor V. I. Mathan (Former Chair, National Institute of Epidemiology, Chennai and Chairman of the Scientific Advisory Committee, NICED, Kolkata) and Dr. Sekhar Chakrabarti (Scientist G and Director in Charge, National Institute of Cholera and Enteric Diseases, Kolkata) for critically reviewing the proposal and the result. The authors also acknowledge the support of Dr. V. M Katoch (Director General, Indian Council of medical Research, Government of India) and Dr. Rashmi Arora, (Scientist G, Indian Council of Medical Research), for providing necessary logistic and administrative support. The Office of the Chief Medical Officer of Malda provided necessary permission and logistic support for the study. The authors are indebted to Prof (Dr.) Rama Prasad Ray, Dept of Community Medicine, Malda Medical College and Hospital for providing critical inputs and operational help in conducting the study. In addition authors also acknowledge the cooperation of the participants and the project staff.

Data Availability

Due to ethical restrictions, data are available upon request. Interested researchers may submit requests for data to Dr. Kamalesh Sarkar (the Corresponding Author) for confidential data preserved under the supervision of the Institutional Ethics Committees of the National Institute of Cholera and Enteric Diseases, Kolkata, India. Further, contact details of the Member Secretary, Institutional Ethics Committee of National Institute of Cholera and Enteric Diseases, Kolkata, India: Dr. Phalguni Dutta, Institutional Ethics Committee, National Institute of Cholera and Enteric Diseases, P-33, C.I.T. Road, Scheme XM, Beleghata, Kolkata 700, 010, India, +91-98300-30188, (drpdutta@yahoo.com).

Funding Statement

The study was funded by the Indian Council of Medical Research (http://icmr.nic.in/Grants/Grants.html) with Grant No. 65/56/2012-13ECD-II. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Due to ethical restrictions, data are available upon request. Interested researchers may submit requests for data to Dr. Kamalesh Sarkar (the Corresponding Author) for confidential data preserved under the supervision of the Institutional Ethics Committees of the National Institute of Cholera and Enteric Diseases, Kolkata, India. Further, contact details of the Member Secretary, Institutional Ethics Committee of National Institute of Cholera and Enteric Diseases, Kolkata, India: Dr. Phalguni Dutta, Institutional Ethics Committee, National Institute of Cholera and Enteric Diseases, P-33, C.I.T. Road, Scheme XM, Beleghata, Kolkata 700, 010, India, +91-98300-30188, (drpdutta@yahoo.com).


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