Health-Seeking Behavior of People in Five Sub-Districts in Karawang Regency

Background: Health-seeking behavior is an individual’s action to maintain and improve their degree of health and/or search for treatment, and it is influenced by many factors. The objectives of this study were to identify the preferences and reasons of people to visit healthcare facilities. Methods: This study was a descriptive study, conducted on November 5th 2019 at five sub-districts in Karawang Regency. Data were collected from all respondents using a guided questionnaire by trained enumerators. The respondents who did not complete the questionnaire were excluded from this study. Data were analyzed using Microsoft Office Excel 2013 and presented inpercentages. Results: Out of 430 subjects, 18.6% were male and 81.4% were female, who were mostly in the age range of ≥ 18 years (99.5%). The sub-district health community center (Puskesmas) was the healthcare facilities most frequently visited and most preferred (39.7% and 40.9%), followed by a private clinic (21.3% and 22.3%) and a midwife (18.1% and 17.9%). Additionally, accessibility, affordability of the treatment cost, and waiting time were the main factors that influence people’s decision in using the healthcare facilities. Conclusion: The sub-district health community center was the healthcare facilities most frequently visited and most preferred by respondents. Accessibility, cost affordability, and waiting time were the factors that influence people’s decision in using the healthcare


BACKGROUND
The World Health Organization (WHO) defines health as a dynamic condition of physical, emotional, spiritual, and social well-being, and not just a state free from a disease or an accident1. This definition can be described as an ideal achievement from those four aspects 2 . Health can also be described as an experience resulting from physical and psychological well-being, where good health and bad health are not a dichotomy but as a unity, so the absence of a disease or disability is not a standard to create good health 3 . In daily life practices, people's understanding of health varies. This can be influenced by many factors, such as their beliefs, culture, age, socioeconomic factors, level of education, and their life experience 4,5 . Health is also considered as abalance, where if it is disturbed subjectively or objectively, it can lead someone to a condition called sickness 1,5 . Being sick is a perception that results from the existence of abnormalities or alteration of a normal bodily physical, emotional, spiritual, or social conditions that interfere with regular daily activities. After someone becomes sick, then they will feel that they need some treatment (perceived need). If that feeling is accompanied by willingness, then there will be a health-seeking behavior 5,6 . Health seeking behavior can be described as an individual's action to maintain and improve the degree of health and/or search for treatment both for themselves or for the people they take care of 7,8,9,10 . Levesque et al., through their conceptual framework of accessibility towards healthcare facilities, explained that health-seeking behavior is influenced by many factors, both from the society and from the healthcare providers11. Good quality of services such as fast wait time, good attitude from the health workers in healthcare facilities, or affordable cost of treatment will influence people's decision to choose healthcare services 12,13 . Besides, distance to travel 9,14,15 , transportation availability 16 , and income 17,18 also influence their decision and health-seeking behavior. The easier the access to healthcare services, the greater is the probability of seeking healthcare services 19 . Accordingly, it is crucial to understand health-seeking behavior because a good health outcome can be achieved from the right health-seeking behavior 20--24 . According to Primary Health Research in 2018, accessibility to healthcare facilities such as hospitals, primary health care, or independent practice of health workers in Jawa Barat is still not good, with the access to primary health care ranked fourth lowest compared with other provinces in Indonesia 25 . Begashaw et al. said that the study of healthseeking behavior is important because it can help related stakeholders develop effective and beneficial policies to improve the degree of public health 26 . Ridwan et al. also explained that the satisfaction from good quality of services from the healthcare facilities would positively impact the loyalty of patients toward the healthcare facilities 27 .
Furthermore, because of the absence of any similar previous research, this present study will be very beneficial to conduct to fill this gap. The objectives of this study were to identify the preferences and reasons of people to visit healthcare facilities.

RESEARCH METHODS
This study was a part of Bumi Walagri program that was called "Penilaian cepat akses layanan kesehatan primer di lima Kecamatan di Kabupaten Karawang tahun 2019". This study was a descriptive study. The respondents were healthy people and patients who visited the Health Community Care (Pusat Kesehatan Masyarakat, Puskesmas) in Batujaya, Rengasdengklok, Tempuran, Lemahabang, and Cikampek sub-district in Karawang Regency on Tuesday, November 5 th 2019. The study setting was chosen by the Health Services of Karawang Regency based on the higher rate of the five diseases that are researched by the Bumi Walagri program, that include: HIV/AIDS, Tuberculosis, Diabetes Mellitus, Leprosy, and people with mental illness.
The inclusion criteria were both healthy people and patients who have been selected and invited to become a respondent by the Health Community Center in Batujaya, Rengasdengklok, Tempuran, Lemahabang, and Cikampek sub-district. The exclusion criteria were the respondents who suffered HIV/AIDS, Tuberculosis, Diabetes Mellitus, Leprosy, or mental illness. The sampling technique was purposive sampling where the respondents were chosen by the Health Services of Karawang Regency.
The instrument used in this study was adapted from the Bumi Walagri research protocol. The questionnaire was comprised of the respondent›s sociodemographic information, most frequently visited and most preferred healthcare, the reason and the barriers of choosing healthcare facilities. This questionnaire was applied to REDCap mobile application. The interview was done by enumerators, who were trained and standardized. They were also given guidelines for using the REDCap application and how to fill out the questionnaires. Moreover, the questionnaires were publicly tested at the Teaching Hospital Padjadjaran University. The data retrieved from the questionnaire were 660 data sets, but only 430 were eligible to use because there were some doubled data and some questions which were answered incompletely so they could not be analyzed. Data were analyzed using Microsoft Office Excel 2013 and presented in percentage.

RESULTS
For the analysis of their reason, two missing data were not included because the answers about healthcare facilities could not be identified. The respondents were mostly female (81.4% vs. 18.6%), and there were just two respondents below 18 years old. Approximately 46.5% of respondents are only a primary school graduate. Around 90.2% of the respondents are married. Most of the respondents (76.5%) answered 'others' about their occupation, and the next most common answer was a housewife. As many as 55.3% of respondents are a member of Badan Penyelenggara Jaminan Kesehatan (BPJS). Around 52.1% of the respondents answered that Health Community Care is the closest healthcare facility to their home, followed by clinic (22.1%). About 75 respondents (17.4%) answered midwives as the nearest healthcare facilities from their home ( Table 1). There were two main questions about healthcare facilities, including: 1) the most frequently visited healthcare facilities; and 2) the most preferred healthcare facilities visited. Subdistrict health community center is the healthcare facilities which were most frequently visited and most preferred by the respondents (39.7% and 40.9%), followed by a private clinic (21.3% and 22.3%). In the third position, there is a midwife (18.1% and 17.9%) (Figures 1 and 2).
The majority of the respondents admit that they like to go to the sub-district health community center because they are easy to access, and their cost of treatment is affordable (49.4%). The respondents who choose private clinics and midwives also admit that access to healthcare facilities is easy (45.8% and 62.3%). They admit that the barrier when they go to the sub-district health community center is the long waiting time (21.5%). However, 27.8% of respondents said they never met any barrier when they went to the subdistrict health community center. Next, the cost of treatment becomes a barrier for those who choose to go to the private clinic (16.6%), while for those who choose to go to the midwife, waiting time becomes a barrier for them (18.1%) (Tables 2 and 3). The percentages in these tables are calculated from the total respondents who chose the related healthcare facilities. The respondents could choose more than one reason.

DISCUSSION
The percentage of the healthcare facilities visited most frequently and most preferred were similar, where subdistrict health community center was the first place, followed by a clinic and midwife in the second and third places. These findings correspond with the study conducted by Ridwan et al. that found people's satisfaction about the service quality of the healthcare facilities positively impacts the patient's loyalty 27 . In Table 2, there is the 'others' option. This category includes private general practitioner, integrated healthcare center (Pusat Layanan Terpadu, Posyandu), and nurses as the healthcare facilities which were the most frequently visited and most preferred for them. In addition, the traditional or indigenous medical practitioner was not discussed in this study because it was only chosen by two respondents, so the result would not be significant.
This study explains that accessibility becomes one of the main reasons people visited sub-district health community center. This because the health community center is the closest healthcare facility for 52.1% of respondents, followed by the clinic (22.1%) and midwife (17.4%). The accessibility to the healthcare facilities depicts that the healthcare facilities' existence is appropriate with people's ability to access it. Furthermore, accessibility to the healthcare facilities can increase the utilization of  19 . Rahman et al. also mentioned that the close distance to the healthcare facilities affects the health-seeking behavior 28 . Ridwan et al. conducted a study on the students at Pondok Pesantren Al Bisyri at Semarang about their health-seeking behavior. The result is that access to healthcare facilities affects student behavior in health-seeking behavior 27 .
Besides accessibility, the affordable treatment cost also was another factor that affects people to choose sub-district health community center. It also indicated that government health budgeting is covered the people, so the treatment cost that has been given by the healthcare facilities do not become a burden. This corresponds with the study conducted by Anggraheni et al. that found the affordable treatment cost significantly affects people's decisions about healthcare facilities 12 site-specific remedial options. However, contemporary approaches aimed at the effective characterisation of contaminated soils for risk assessment, remedial and regulatory purposes are frequently challenged by knowledge gaps in contaminant bioavailability, mixed contaminant effects and emerging contaminants.
Understanding mixed contaminant interactions at the elemental and molecular levels is, therefore, imperative not only to explain the underlying mechanisms controlling the fate and transport of these contaminants in soils, but also predict their bioavailability, ecotoxicological effects on natural communities under realistic exposure conditions and remediation endpoints. In this paper, scattered literature is harnessed to review specific soil-contaminant interactions, inter-contaminant (metal-metal, organic-organic, metalorganic. According to the study conducted by Chauhan et al., people tend to choose governmental healthcare facilities because their treatment cost is usually cheaper 29 . That is suitable with the findings that most respondents in this study choose sub-district health community center, a governmental healthcare facility. Then, although access to the private clinic is easy, the treatment cost becomes a barrier. There is no government subsidy to the private clinic, so the cost is on their own responsibility. The impact is that only the middle-and high-class society seek a private clinic, while the lower-class society will choose the cheaper facilities. This finding is consistent with the Selma et al. study that found cost is one of the barriers for most people to choose private healthcare facilities 30 .
Another barrier for respondents who choose sub-district health community centers is waiting time. This finding corresponds with the study conducted by Shaikh et al. that found service quality, such as short waiting time, could affect people's decision about healthcare facilities 13 . Selma et al. found that people's perception of the government healthcare facilities is already good, but they still have procedural problems and complicated administration 30 . This could be an evaluation for the government to fix these barriers; for example, they can shorten the registration procedure or change the administration methods so that it will become easier and faster. This study also shows that waiting time becomes a barrier for respondents who choose a midwife. This may be because many people want to go to the midwife, but the midwife's availability is limited. Maybe the government could make the midwife's number and distribution more evenly distributed to meet the people's needs.
There are some limitations in this study. The questionnaire that was used in this study is normally completed in 30-40 minutes, which may have affected the respondent's concentration in answering the questions. Moreover, even though the interviewer was previously trained, there was no direct supervisor during the interview, so the expected standard answers were not maximally fulfilled; for example, in Table 2, there is a 'missing' category for those who answered the healthcare facilities without mentioning their types.

CONCLUSIONS
This study concludes that the sub-district health community center is the healthcare facilities most frequently visited and most preferred by the people in five sub-districts in Karawang Regency, followed by a private clinic and midwife. Then, the main reasons that affect people's decision about healthcare facilities are the accessibility and the affordable treatment cost, except for the clinic. Instead, the treatment cost becomes a barrier for them, whereas for the sub-district health community center and midwife, the barrier to choose these healthcare facilities is the long waiting time. Moreover, this study's overall result shows that people's satisfaction with healthcare facilities affects their choice of healthcare facilities.
People, of course, have their own preferred healthcare facilities option to choose. This should be a concern of the healthcare provider, so they can continue to improve their service quality. On the other side, the government can consider these findings to make an effective and beneficial policy for society, especially about the healthcare facilities. To maximize the results of the similar study in the future, the analysis of health-seeking behavior should be collaborated with the data of the geographic availability of the healthcare facilities.