FACTORS THAT INFLUENCE UTILIZATION HEALTH CARE SERVICES

HOSPITAL AND MCH IN BURAO DISRICT

SUBMITTED BY:

MUSTAFE HASHI IBRAHIM

IDNO: BIO3CM/073

LECTURED BY:

Mr. MOHAMED ABDURAHMAN OSMAN

SUPERVISED BY:

Mr. MOHAMED ABDURAHMAN OSMAN

BACHELOR OF SCIENCE IN CLINICAL MEDICINE

A Dissertation submitted to the Faculty of Health Sciences in partial fulfillment of the

requirements for the degree of Bachelor of Science in Clinical medicine at Gollis
University, Burao Campus

August, 2016
 GOLLIS UNIVERSITY RESEARCH CENTRE (GURC)
BURAO CAMPUS
2016 RESEARCH CERTIFICATE

This is to certify that the following student:

Name of student: Batch No.: ID. No.:

Mustafe Hashi Ibrahim Hussein B03 073

Of B03 Year 4, Course in BSc. in CLINICAL MEDICINE has successfully completed his
Research Activity and Dissertation writing on

FACTORS THAT INFLUENCE UTILIZATION HEATH CARE SERVICES HOSPITAL

AND MCH IN BURAO DISTRICT
In the partial fulfillment of requirement as prescribed by the Board of Higher
Education, Somaliland State, in the year 2016.

DISSERTATION GUIDE
Faculty Dean
Burao Campus

INTERNAL EXAMINER EXTERNAL EXAMINER

_________________________
DIRECTOR, GURC

ii
 PPROVAL SHEET

This thesis entitled (Factors that influence utilization of health care service in

hospital and MCHs in Burao) in burao-Somaliland ‟in partial fulfillment of requirement

for the degree of bachelor of (Clinical Medicine) has been examined and approval by the

panel or oral examination with grade of pass.

SUPERVISOR

Mr. Mohamed Abdirahman osman

Signature…………………………………..

Date……………………………………………

iii
 DEDICATION

I dedicate this thesis to my parents, brothers, sisters and to my population be loved

Somali landers, thanks all of you……for everything.

Love you

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 ABSTRACT

There are many factors that influence health and health care services. Although many of

these factors are similar across populations, precisely how they interact and influence the

actions of people is often exclusive to a population in the context of the environment they

live in. The current study, a population-based cross sectional survey, identifies four

specific villages‟ populations in burao city republic of Somaliland, to gain information

regarding overall influences on health care services, and also information specific to each

area to directly target the health needs of the individual population living there.

Participants of the survey were interviewed for personal information and details

regarding their activities in response to their health and ill-health. The subsequent data

was then analyzed to determine which factors affected the use of health and medical

services within the study areas and whether the study participants believed their health

needs were being met. Just over half the population surveyed had been sick and required

treatment, 73.9% used formal health care services over informal services with more

preferring formal if they had the choice. There were some differences according to

gender, education of respondents, while other factors such as the costs associated with

seeking treatment, distance and time taken to travel also affected health care service use.

Some limitations of the study and areas for further investigation include better

clarification of the difference between private health care services that involve health

center and those that involve private providers such as hospitals. The current study did

not assess perceptions of the quality of service, disease severity or the number of disease

incidents.

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 DECLARATIONS

I, Mustafa Hashi Ibrahim, declare hereby that this study is a true reflection of my own

research, and that this work or part thereof, has not been submitted for a degree in any

other institution of higher education.

No part of this thesis may be reproduced, stored in any retrieval system, or transmitted in

any form, or by any means (e.g. electronic, mechanical, photocopying, recording or

otherwise) without the prior permission of the author, or The University of Gollis at

Burao Campus in that behalf.

I, Mustafa H. Ibrahim, grant The University of Gollis the right to reproduce this thesis

In whole or in part, in any manner or format, which The University of Gollis may deem

fit, for any person or institution requiring it for study and research; providing that, the

University of Gollis shall waive this right if the whole thesis has been or being published

in a manner satisfactory to the University.

Supervisor‟s Name:…………………………………….…

Supervisor…………………………………………………

Date:……………………………..

vi
 ACKNOWLEDGEMENTS

Alhamdulillah this research would not have been possible without ALLAH guidance. I

would like to express my sincere thanks to my supervisor Mr. Mohamed Abdurahman

Osman for his supervision, guidance, encouragement and interest throughout the last

four years. Many thanks are extended to. For his continuous help support, for their hard

work and support during the survey process and in the laborious collating of data after the

field work was done.

Since the respondents were guaranteed confidentiality, I cannot thank them by name, but

nonetheless wish to express my graduate to them for devoting time and efforts to the

success of this research. In fact the research could not have been done without their

generosity. Also special thanks also go to all members of research community of at

Somaliland Ministry of Health for their support and guidance.

None of my academic success would have been possible without the love and support of

my friends. Finally and most importantly, I am also deeply indebted my Mather for her

support, also special thanks go to my young brothers and sisters who helped me give of

myself, with you I am nothing I want to be, without you I am nothing at all.

vii
 LIST OF ABBREVIATIONS

WHO: World Health Organization

MCH: Maternal and Child Health

WB: World Bank

ICF: International Classification of Functioning

UNDP: United Nations Development Program

HIV: Human immunodeficiency virus

AIDS: Acquired immune deficiency diseases syndrome

°C: Centigrade

°F: Ferhanight

SPSS: Statistical Package for social science

NGO: Non-Governmental Organization

NCPD: National Council for Population and Development

CBS: Central Bureau of Statistics

viii
 Table of Contents
PPROVAL SHEET .............................................................................................................................. iii
DEDICATION ................................................................................................................................ iv
ABSTRACT......................................................................................................................................... v
DECLARATIONS ............................................................................................................................... vi
ACKNOWLEDGEMENTS .................................................................................................................. vii
LIST OF ABBREVIATIONS ....................................................................................................... viii
CHAPTER 1 .................................................................................................................................... 1
INTRODUCTION ........................................................................................................................... 1
1.1 Introduction to Study ............................................................................................................. 1
1.2 Background to the Study ........................................................................................................ 2
1.3 Statement of the Problem ....................................................................................................... 3
1.4 Scope of the Study ................................................................................................................. 3
1.5. Purpose of the Study. ............................................................................................................ 4
1.6 Objectives of the Study .......................................................................................................... 4
1.6.1 Major objectives.............................................................................................................. 4
1.6.2. Specific objectives .......................................................................................................... 4
1.7 Definition of Key Terms ........................................................................................................ 4
1.8 Significance of the Study ....................................................................................................... 5
1.9 Limitations to the Study ......................................................................................................... 6
1.10 Theoretical Frame work ....................................................................................................... 6
CHAPTER 2 .................................................................................................................................... 8
LITERATURE REVIEW ................................................................................................................ 8
2.1 Introduction ............................................................................................................................ 8
2.1.1 What does meant by Health? .............................................................................................. 9
2.2 Factors Influencing Health care ........................................................................................... 10
2.2.1. Socio-Demographic Characteristics ............................................................................. 10
2.2.3. Factors Related to Accessibility ................................................................................... 16
CHAPTER 3 .................................................................................................................................. 21
METHODOLOGY ........................................................................................................................ 21
3.1 Introduction .......................................................................................................................... 21
3.2 Research Design................................................................................................................... 21

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 3.3 Study Area and Population .................................................................................................. 22
3.4 Sampling Techniques ........................................................................................................... 23
3.5 Data Collection Methods ..................................................................................................... 23
3.6 Interpretation ........................................................................................................................ 24
CHAPTER 4 .................................................................................................................................. 25
DATA PRESENTATION AND ANALYSIS ............................................................................... 25
4.1 Data presentation and Analysis ............................................................................................ 25
4.2 Presentation of results .......................................................................................................... 26
CHAPTER 5 .................................................................................................................................. 49
SUMMARY AND RECOMMENDATIONS ................................................................................ 49
5.1 Summary of findings............................................................................................................ 49
5.2 Discussion of findings.......................................................................................................... 50
5.3 Recommendations based on findings ................................................................................... 51
APPENDICES ............................................................................................................................... 53
Appendix A: Community Questionnaire ................................................................................... 53
Appendix B: Professional questionnaire .................................................................................... 58
REFERENCES .............................................................................................................................. 61

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 CHAPTER 1

INTRODUCTION

1.1 Introduction to Study

This Research thesis was aimed at providing the reader with all my intended activities

pertaining my research. In general, it talks about the reasons for my undertaking of

factors that influence hospital and MCH health care services as a major problem/issue in

burao city.

This study inspects factors which influence the use of health and medical services,

specifically health care seeking behavior .demographic and socioeconomic data, as well

as information relating to the activities of people that reported being ill in the past three

months. The subsequent data was then analyzed to determine which factors affected the

use of health and medical services within the study area and whether the study

participants believed their health needs were being met. The larger project was aimed at

identifying surrogate measures to facilitate the detection of infectious diseases. The

alternate markers studied included physical and environmental characteristics such as

types of housing and sanitation, and socio-demographic aspects such as age, marital

status, family breakdown and occupatin. Barriers to healthcare access for people with

physical impairments are important because it can help to test and validate measures to

improve equitable access to health services. The World Health Organization (WHO) and

World Bank (WB) (2011), on the other hand, defined disability as: “Difficulties

1
encountered in any or all three areas of functioning. These are: example, paralysis or

blindness; Furthermore, “The International Classification of Functioning (ICF) model can

also be used to understand and measure the positive aspects of functioning such as body

functions, activities, participation and environmental facilitation. The ICF adopts neutral

language and does not distinguish between the type and cause of disability – for instance,

between “physical” and “mental” health. “Health conditions” are diseases, injuries, and

disorders, while “impairments” are specific decrements in body functions and structures,

often identified as symptoms or signs of health conditions. Disability arises from the

interaction of health conditions with contextual factors – environmental and personal

factors” (WHO & World Bank, 2011). The SARS (2009: p1) defines what physical

impairments are.

1.2 Background to the Study

Poor health care service has always been in existence for a long period of time. Several

agencies have tried to take all possible actions in order to eliminate all the effects related

to .factors that influence hospital and MCH health care services research problem.

However, this problem/issue has always been in existence and therefore calls for further

research in order to find the most possible and effective solutions. The current works

acknowledges there are multiple determinants of health, which recognize the role of

biology, behavior, culture, economics, psychological, environmental and social factors

and the interconnectedness of theses (Ansari, Carson,Ackland, Vaughan, & Seraglio,

2003; Celik & Hotchkiss, 2000; Hunt, 1994; Thisted,2003). In developing countries,

these factors are newer considerations as countries with limited resources struggle to cope

2
with mortality and morbidity as a result of communicable disease, injury, poverty, sexual

and reproductive health issues, and more recent concerns such as hypertension, heart

disease (Naicker, 2003) and diabetes that aremore lifestyle-oriented results of

development (Correa-Rotter et al., 2004).However, more recent studies are beginning to

discover that unless health and ill-health in less developed countries is considered in this

broader context, inequalities will only become more evident (Gwatkin, 2000).

Therefore,knowledge of the patterns that influence the use of health and medical services

in developing countries are needed to address this.

1.3 Statement of the Problem

There was the existence of challenges of health care services while considerable research

has been done on health care access, use and satisfaction among those with physical

impairments worldwide, (Obrist et al., 2007; Oliver & Mossialos, 2004) there is very

little work done on access barriers for people with physical I pairments in b (Bell &

Iithindi, 2002) and this study hopes to fill the gap in literature. Recent work in the health

sciences field has shown that more than 70% calls for immediate actions on the actions

that should be done in order to solve this problem since its further existence might lead to

more damage and destruction of human lives or losses to an organization. In General, the

situation is poor and yet I should be needed to solve the berries behind poor health care.

1.4 Scope of the Study

My research carried out in the period between March and August 2016 in Togdheer

region in burao City.

3
It was strictly be concerned with the challenges hospital and MCH health care services

and possible ways of solving it.

1.5. Purpose of the Study.

My research has a major purpose to display factors that influence utilization of health

care services in hospitals and MCHs.

1.6 Objectives of the Study

1.6.1 Major objectives

 In order to investigate factors which influence the use of health and medical services

in hospital and MCH in burao district, this study explores health care seeking

behaviour in the study population, their characteristics and ability to access services,

preferences and whether their health needs are being met.

1.6.2. Specific objectives

The following shall form part of my final target:

– To identify factors that influence utilization of health and medical services

– To investigate health and medical services are preferred

– To Determine characteristics affect access to these services

– To study participants able to access the services they need

1.7 Definition of Key Terms

 Health: the world health organization (WHO) defines health as a state of

complete physical, mental and social well-being (WHO, 1946)

4
  Healthcare: can be explained in terms of primary, secondary and tertiary

prevention.

 Primary prevention: is concerned with eliminating risk factors for a disease.

 Secondary prevention: focuses on the early detection and treatment of disease

(sub-clinical and clinical)

 Tertiary prevention: is an attempt to eliminate or moderate disability associated

with advanced disease.

 Health care service: it is often described by its function, structure, activities or

characteristics.

 Human function: comprises information relating to dis ability.

 Deaths: includes the mortality rates in relation to the age and /or condition.

 Impairment: problems in body function or alterations in body structure; for

example, paralysis or blindness.

 Activity limitations: difficulties in executing activities; for example, walking or

eating;

disability as defined. This means the restriction on the person‟s ability to function

or perform daily activities after maximum correction is less than a moderate to

severe limitation.

1.8 Significance of the Study

Due to the fact that there exists people/organizations in burao areas and Somaliland at

large, it‟s a clear indication that they deserve the best in life/organizational growth. They

ought to be educated and protected from all sorts of negative issues that could harm their

lives/organizations.

5
Living/having a healthy life/successful accomplishments is paramount and so relevant in

human lives/organizations and thus it encourages me to go ahead and carry out my

research concerning challenges hospital and MCH of health care services in burao town

owing to the fact that majority of the people/organizations have for long been suffering

from such negatives/poor services.

1.9 Limitations to the Study

• Non-compliant of firms; some people may not readily provide the required data

concerning their businesses.

• Language challenges because most people do not speak English so the research

clerks will be barred.

• Suspicion by the government agencies fearing of the researcher being a spy.

• High costs of vehicles, internet, stationary and paying the research clerks

• Limited time; combination of extreme work and research preparation.

• Lack of skilled people in some partnership firms And many more

1.10 Theoretical Frame work

This Research thesis consists of five chapters; each one has its own indication and

detailed explanations below, there is additional hypothesis which shows the material

collected and integrated idea about the thesis paper.

The first chapter concentrates on all the basics of the thesis by telling some basic

information that are related to the thesis paper incorporated with overview of the thesis

6
paper, core of the paper. Introduction of the thesis paper; which tells how the thesis has

been developed and arranged on the basis of factors that influence health care services.

Thesis background, which highlights on the basic background and fundamental principle

of my study. Thesis statements; which tells how thesis is organized and directed under

the study. Objective of there search study, including identifications and explanations.

Significance: this shows how important this study is to several clinics .

Scope of the study that limits me to a particular area of concentration on my study and

several more.

Second chapter focuses on “Literature review”; including an overview, history, plan and

schedule.

Third chapter discusses the research methodology which also forms the core of the

thesis and incorporate with the “research designing, method of data collection which are

two “primary and secondary”, in-depth interview and data collection source, sampling

methods, and analyzing techniques.

Fourth chapter is determined in analyzing the findings that includes data presentation

and interpretation, data analyzing and hypothesis testing, and findings, and accounts that

are frequently misstated.

Fifth chapter addresses the conclusion and recommendations and look-over the serious

coherence of inventory management and reports, recommendation has been applied on

the basis of research.

Finally the paper is concluded with Appendices and Reference that have been selected

among the books including health related books, Websites and others.

7
 CHAPTER 2

LITERATURE REVIEW

2.1 Introduction

The current literature acknowledges there are multiple determinants of health from which

wediscern there are many factors that influence health care seeking and the use of health and

medical services. This review provides an outline of the literature on health seeking and health

care seeking and details the concept of a determinant. As there are many determinants that

could be discussed a number have been singled out from the literature. Each is presented in a

discussion of its significance to the study and why it was chosen as a determinant. These

factors reflect two different aspects of health care seeking: the socio-demographic

characteristics of the individual, and their ability to access health care services. This study

investigates the characteristics that may affect health care seeking behavior, these are gender,

literacy, education, regular income and age. The other part of this study investigates issues of

access as they affect health care seeking and are communications, mode of transport, closest

health or medical facility type, travel time to nearest health or medical facility and if people

were able to access these health care facilities. The district respondents resided in is also

important. Although the three districts are all rural areas, they are still diverse in composition.

As this study is specifically concerned with the use of health and medical services, the types

of services and treatment that are available to the participants of the study will be reviewed.

Most commonly these are divided into: formal and informal services, and private and public

services. As the intention of the study is to use the information to improve the health situation

8
 of the surveyed populations, the objective of this research is to determine if the need for health

care service use is being met. This will be a subjective measure according to the perceptions

of the study participants. The literature involving unmet health needs discusses the importance

of the attitudes and perceptions of individuals.

2.1.1 What does meant by Health?

Current literature recognizes the importance of the processes which may determine our health

and “the interconnected nature of people‟s complex lives and contextualizes biological health in

its social, economic, cultural and psychological dimensions” (1994, p. 340). The „life span‟

approach acknowledges human health and illness as an accumulation of conditions that begin

early in life and sometimes even before birth, and recognizes these as dynamic and on a

continuum of risk over the entire course of a lifetime (Institute of Medicine, 1996). Health, as

such, is the sum of genetic determinism and a combination of physiological, psychological and

environmental factors. And it is a statistical fact that people in less affluent countries experience

higher rates of death and disease than those in richer countries (World Bank, 93).

Factors which are known to influence population health in lower income countries include

education levels, access to safe water and sanitation, environmental, social and cultural

factors, as well as access to effective health services. (Remer, 1991, cited in Moore, Castillo,

Richardson, & Reid, 2003,p.280 ).

With the increasing emphasis on globalization, demographic and epidemiologic change and

more accessible technologies, developing countries are experiencing new dimensions of

health and ill-health (Andrews, 2001; Correa-Rotter et al., 2004; Heiberg, 1996; Institute of

Medicine, 1996). These dimensions are reflected in social, cultural and environmental change

9
 and the experience of the kinds of chronic health problems that come as a result of this change

(Andrews, 2001; Bicknell & Parks, 1989).

Already overburdened health systems in developing countries need better information to

prioritize and target their limited resources (Ensor & Cooper, 2004; Nyamwaya, Nordberg, &

Oduol, 1998; The Working Group on Priority Setting, 2000

2.2 Factors Influencing Health care

Before reviewing some of the factors or determinants that influence health and health care use,

two points are worthy of consideration. The first is the difficulty of separating these factors into

discrete categories, which reinforces the point that it would not be accurate to view these

determinants in isolation, but rather in terms of the larger context and as part of a process. The

second point is that while the “concept of a determinant is tied to the idea of a mechanism for

action” (Thisted, 2003, p. 65. A comprehensive review of the literature about inferring

causation is beyond the scope of this dissertation.

2.2.1. Socio-Demographic Characteristics

2.2.1.1 Gender

„Gender‟ has often been used interchangeably with „sex‟. „Gender‟ is a social construct that

refers not only to the biological „sex‟ differences between men and women, but to the

different roles and expectations, behaviours and constraints that are placed upon an individual

by culture and society, by virtue of their sex. Until the last two to three decades, little attention

had been paid to women‟s health as it was assumed that the male biological model could

simply be adapted (Vlassoff, 1994). Where women‟s biology was so obviously different, it

10
 was treated from a reproductive health perspective, as almost a separate entity from the

woman (Broom, 1991), with little to no consideration of the other factors which may

influence health.

Many health indicators for adults exhibit considerable gender differences according to an

individual‟s social position and role (Berhane, Hogberg, Byass, & Wall, 2002, p. 714). As these

issues are being addressed in industrialized countries, there is recognition of the specific health

needs of women and the complex nature of the determinants of health for both women and men.

It is believed that researchers, clinicians and policy makers would understand and address both

sex-specific and non-sex-specific health problems differently if the social as well as biological

sources of differences in men‟s and women‟s health were better understood. (Bird & Rieker,

1999, p. 745).

In developing countries this process still has some way to go, where women‟s often lower status

persists and can be reflected in the socioeconomic disparities that frequently cause women to

suffer poorer health (Nash Ojanuga & Gilbert, 1992; Puentes-Markides, 1992; Vlassoff, 1994).

It was not until 1985 at the Third World Conference on Women in Nairobi that a solution to

these problems was posed in the commitment to improve the access of women to health and

social services, to education, to credit facilities and to other resources that might enhance their

own well-being, while at the same time maximizing their contribution to the wider community.

(World Health Organization, 1998, n.p. ).

The main criticism inherent in these „solutions‟ however is the overriding assumption that

women are somehow passive recipients of whatever it is felt should be good for them.

11
Certainly, „gender‟ has become a fashionable word for government and nongovernment,

international and national organizations. The fact remains that in developing countries there is

still inadequate understanding of how gender influences health itself (AbouZahr, Vlassoff, &

Kumar, 1996; Goding & Howie, 1990; Nash Ojanuga & Gilbert, 1992), access to health

information (AbouZahr et al., 1996) and services (EQUINET Steering Committee, 1998; Nash

Ojanuga & Gilbert, 1992; Vlassoff, 1994) health-seeking behaviour (Ahmed, Adams,

Chowdhury, & Bhuiya, 2000; Puentes-Markides, 1992; Tanner & Vlassoff, 1998; Vlassoff &

Garcia Moreno, 2002) and the use of services (Buor, 2003; Hjortsberg, 2003), treatment and

attitudes of providers (Hartigan, 2001; Nare, Katz, & Tolley, 1997; Oliveira-Cruz, Hanson, &

Mills, 2003; Puentes-Markides, 1992), and health outcomes (AbouZahr et al., 1996; Ahmed et

al., 2000; Hjortsberg, 2003). This is important because if we believe that health is genetically,

biologically, ecologically, culturally and socially determined, then gender must be recognized as

being one of these determinants as it is interconnected with biology and the socio-cultural

factors that affect health (Vlassoff & Garcia Moreno, 2002). Once it is established that gender

does play a role in health, the focus can be taken away from „gender‟ per se and turned toward

the social divisions of the sexes, so called „gender relations‟ (World Health Organization, 1998).

2.2.1.2 Education

A key socio-cultural determinant of health is education (Kickbusch, 2001). Again it is difficult

to separate education from literacy and other indicators that are regularly used as convenient

markers of socio-economic status. Available data in all countries points to the relationship

between the risk of disease and lower levels of education (Mackenbach & Howden-Chapman,

2003; Marmot, 1999). Occurrence of illness is significantly lower in groups with higher

education, especially among men, but there was no difference between occupational and

12
economic groups in Vietnam (Giang & Allebeck, 2003). Buor (2003) finds that in Ghana

“…higher education resulted in higher utilization…” of health facilities (p. 308). While in

Africa generally,

Poverty, low levels of education, poor leadership, and man-made as well as natural disasters

have been recognized as factors in health development (Nyamwaya, 2003, p. 86).

While there has been an increase in formal education levels in sub-Saharan Africa in recent

years (Adamchak & Ntseane, 1992), levels of education are generally lower for women than

men in developing countries (United Nations Development Programme, 2001), as they are also

for minority groups in developed countries (Cooper, 2002), immediately creating health equity

issues.

Women in developing countries are frequently confronted with a myriad of socio-cultural

factors which negatively impinge upon physical well-being and accessibility to appropriate

health care services. An institutional, economic, and educational barrier effect and lowers

their standard of living when compared to their male counterparts (Nash Ojanuga & Gilbert,

1992, p. 613).

Education is tied to gender, culture, social status, occupation and economic wellbeing. It is

difficult to make any definitive statements about education without including socio-economic

status. The World Bank views the two as interlinked and regard the “economic and social

benefits of education for girls and women as a form of human capital investment” (cited in

Moss, 2002, p. 650) as well as poverty reduction, specifically in Africa (Nduru, 1999).

Secondary or higher education consistently correlates with modern family planning practices

and contraceptive use (Magadi & Curtis, 2003; Nash Ojanuga & Gilbert, 1992; National

13
Council for Population and Development (NCPD), Central Bureau of Statistics (CBS), Office of

the Vice President and Ministry of Planning and National Development (Kenya), & Macro

International Inc., 1999; No author, 1994; Sarkar, 1995; Tuoane, Diamond, & Madise, n.d.), and

negotiation of these with a partner (Greig & Koopman, 2003; Lagarde et al., 2001).

2.2.1.3 Income

Income is used in this study as a determinant for health care seeking behaviour, and has been

used in previous studies to determine not just health seeking behaviour, but risk factors

associated with health outcomes (Colin, Adair, & Popkin, 2004; Mackenbach & Howden-

Chapman, 2003), barriers to seeking health care (Taffa & Chepngeno, 2005), types of treatment

(Nyamongo, 2002) and delays in service use (Johansson, Long, Diwan, & Winkvist, 2000) for

example.

Income is one of the factors used as a measure of socio-economic status (Dressler, Balieiro, &

dos Santos, 1998) (Pavlova, Groot, & van Merode, 2003) (Rosenberg & Hanlon, 1996)

(Matthews & Power, 2002) (Mehrotra & Jarrett, 2002; Zwi & Yach, 2002) and it is socio-

economic status that is often used as an indicator of health. There is a large body of literature

regarding health status and health outcomes as a result of socio-economic status. These studies

are measured in many ways often using indicators that are convenient such as education

achieved, literacy level, employment and other lifestyle measures or a combination of these

factors. Literature regarding income, separate to the category which is socio-economic status is

more sparse.

How low income affects health, and what the relative importance of different pathways related

to low income is…far from clear (Mackenbach & Howden- Chapman, 2003, p. 431)

14
Many studies identify economic status as the most significant predictor of service use (Pillai et

al., 2003) and how income affects the level to which health care facilities are sought and used

(Buor, 2003, p. 296). While often the decision to seek health care is based upon the cost as

compared to the perceived benefit (Hjortsberg, 2003).

2.2.1.4 Age

Age is a factor associated with health (for example Kaplan, Newsom, McFarland, & Lu, 2001;

Mishra, Ball, Dobson, Byles, & Warner-Smith, 2002). It can be a determinant on its own or in

conjunction with other factors. Age can be considered a factor of greater vulnerability, as with

children under five years or the elderly, or greater robustness, or because the age group 18 to 25

years is more likely to be engaging in higher risk behaviours such as sexual activity, and

alcohol, tobacco and other drug use. It is a useful demographic indicator.

Worldwide, there is an increase in the aged...

For many developing countries, rapid population aging and the phenomenon of a "double

burden" of both infectious disease and emerging chronic diseases represent a major challenge.

Many of those who will contribute to these extraordinary transitions will live in rural areas.

Many countries, especially the poorest, still have a huge burden of infectious diseases, including

increasing rates of HIV/AIDS along with a growing problem of chronic diseases…(Andrews,

2001, p. 323)

Chronic diseases may include diabetes (Naicker, 2003), heart disease (Correa-Rotter et al.,

2004) or osteoporosis for example (Woolf & Pfleger, 2005), and the possibility of longer term

burden to caregivers (Wiet, 2005).

15
The effects of age can be due to differences in socio-economic status as defined by

employment, education and income (Mishra et al., 2002), as well as greater economic

dependency, poor housing, loneliness and lowered self-esteem (Waweru, Kabiru, Mbithi, &

Some, 2003).

2.2.3. Factors Related to Accessibility

2.2.3.1 Transport

There are few studies specific to types of transport and their relationship to health care

utilization. In the majority of discussions regarding access to health care facilities, types of

transport, the time taken to travel to the nearest health facility, transport cost and the condition

of roads are assessed as a single variable (Buor, 2003; Noorali, Luby, & Rahbar, 1999) such as

physical or geographic access or socio-physical environment (Odhiambo-Mbai, 1992). This is

also the case in studies from more developed countries (Wellstood, Wilson, & Eyles, 2006). A

discussion of mean distances for health care utilization in Kenya is offered by Noor (2005).

Peterson et al (2004) talk about the failure of health care referrals and follow up due to lack of

finances, time and mode of transport. McCray (2001) and Odhiambo-Mbai (1992)also use mode

of transport as one of the factors to be included in the overall discussion of health care

utilization and barriers to health care for populations in South Africa and Kenya. Hjortsberg

(2003) asserts individuals that were sick and given the option of seeking health care or self-

medicating would make a decision based on the cost of accessing health care and the perceived

benefit of receiving health care. Individuals were “influenced by income, insurance, type of

illness and access variables such as distance and owning a vehicle “(p. 755).

16
 2.2.3.2 Closest Facility Type

This determinant is concerned with which type of health facility is more available to prospective

users. This would include the level of expertise and treatment that could be assumed from the

type of facility, that is a hospital versus a dispensary, or if public facilities are limited and not

accessible, so private facilities have filled the gap, as is the case in Vietnam (Ha et al., 2002;

Tuan, Dung, Neu, & Dibley, 2005), or Uganda (Birungi, Mugisha, Nsabagasani, Okuonzi, &

Jeppsson, 2001; Witter & Osiga, 2004) , or India (Rajeswari et al., 2002; Sudha et al., 2003).

Accessibility issues for those living in rural areas are well documented, whether it be in

developed countries (Andrews, 2001), or developing countries (Mehrotra & Jarrett, 2002). This

is not the only issue facing those in rural areas, where there may be questions about the quality

of the service, capacity or the facilities of the nearest service. Perhaps there are few options for

residents of that area, and with limited choices they are bound to use any health facility, over

taking no action at all. Or perhaps instead they turn to alternative therapies (Eisenberg et al.,

1998), traditional methods (Good & Kimani, 1980) and/or self-medications (McCombie, 2002;

Schulpen & Swinkels, 1980).A number of factors influence the choice of a health service

physical access to health care, including distance from the health facility, availability of

transportation, and the condition of the roads. The distance separating potential patients from

the nearest health facility is an important barrier to it‟s use, particularly in rural areas . (Noorali

et al., 1999, p. 191) Again this means difficulties with separating out variables directly

responsible for health seeking and service choice. There are also other factors which may be the

primary determinants for the use of some health facilities over others, particularly for treating an

ill child for example (Noorali et al., 1999).

17
 2.2.3.3 Travel Time

As with type of transport and closest health facility, time taken to travel to a health facility is

often discussed in terms of geographic or physical access. This makes comparison with other

study results difficult “as most of the available literature has focused on the influence of

physical accessibility on the use of health services in general” (Noorali et al., 1999, p. 194 ).

The determinant „travel time‟ seeks to include a number of issues addressing access to health

and medical services. Actual distance in kilometers or miles is an easier measure, but does not

seem an accurate representation of what logistical barriers may be involved. That is, the

distance to travel to a health or medical facility may be kilometres, but on a surfaced road using

motorized transport this may take 30 minutes and be far more achievable than 5 kilometres on a

donkey over rough terrain. Not to mention what that journey might do for the ill person. „Travel

time‟ in this context is used as part of a combination of determinants to better understand the

patterns influencing health care seeking. The assumption is that the longer the travel time to a

health care facility, the least likely individuals are to use it. Therefore one would expect that

“improved geographic access could increase the overall use of PHC [primary health care]

centres” (Onwujekwe, 2005, p. 455) page number. In some cases this may hold true. For

instance, in the United Kingdom where Haynes, Bentham, Lovett and Gale (1999) showed that

the distance to facilities had a bearing upon visits, that is, the further the distance the less likely

people were to go there. But as previously discussed many considerations go into the decision to

access health care. …[J]udgements of efficacy, cost, distance, and the availability of time and

transport may affect decisions made by the patient and their family (Macintyre, Lochigan, &

Letipila, 2003, p. 24) While Buor (2003) found income, service cost, education, waiting time

and transport cost seemed to be the main variables in order of importance, for his research in

18
Ghana. He also found that of transport cost and travel time, it was travel time that showed the

greatest correlation with distance and utilization. In Uganda, distance, cost, quality of service

and health workers attitudes influenced peoples choices of a health service (Witter & Osiga,

2004).

2.2.3.4 Private/Public

The definition of private and public is not so simple as to say one is not-forprofit and one is for-

profit. The public sector is generally viewed as health care under the auspices of the state or

government (Birungi et al., 2001), while it seems that everything outside that category can be

viewed as private. The private health care sector includes Accredited outlets and hospitals, but

also many unregulated hospitals, edical general practitioners, homeopaths, …

traditional/spiritual healers …herbalists, bonesetters and quacks.(Shaikh & Rabbani, 2004 p. 50

Also in this study “self-medication with pharmaceuticals bought over-thecounter on the open

market” (Nyamongo, 2002p. 377) is included as well as “medicines sold in the markets and

streets” (Msiska et al., 1997p. 250) and „mganga‟/‟wagangas‟, which is the Kiswahili name for

traditional healers. Private health care in this study also includes hospitals, health centres,

clinics and dispensaries that are run by nongovernment organizations such as mission hospitals

or those institutions run by private companies for their workers, such as the sugar industry.

There is an ongoing debate in developed countries about how one may deal with the health care

of populations and the economics of maintaining public health care services in their present

form (Hoyt, 2005). The general consensus seems to be, this is not possible, particularly with

treatment becoming more expensive (Pauly, 2003) and that there need to be new strategies to

mix public and private. However, according to Birungi (2001) among others, there has generally

been a pragmatic blend in developing countries such as in Uganda where it has always existed.

19
Treatment cost has a significant impact. In Pakistan, Noorali (1999) found cost was significant

for “ use of a government facility; the less the cost, the greater the use of a government facility “

( p. 194). A similar finding in Sri Lanka determined those with more money would prefer to use

a private facility (Akin & Hutchinson, 1999). In sub- Saharan Africa, Filmer (2005) writes that

incidence of fever and…treatment patterns are strongly related to poverty as wealthier

households are more likely to seek care or advice.

20
 CHAPTER 3

METHODOLOGY

3.1 Introduction

Each study site in this cross-sectional population-based survey was unique. Planning and

logistics were significant issues as was data management. The methods used will be

presented in the following sections.

3.2 Research Design

This study uses a population-based, cross-sectional survey design to investigate the

factors that influence utilization of health and medical services in Burao city,Togdheer

region in the Republic of Somaliland. Self-reported information was gathered about

gender, literacy, education level achieved, measures of income, age, access

telecommunications and transport, type and time taken to reach the nearest health facility,

whether participants report receiving all the health care they needed, the use of formal or

informal and public or private health services, and preferences for seeking health care. A

cross-sectional study design was chosen because the data collected relates to a single

specified time and also includes some historical information. The study was not expected

to measure changes in status or at different points in time. Other study designs were

considered but economic and time constraints posed limitations on their use. Self-

reported rather than observational data was chosen for logistical reasons such as the costs

for materials, time and personnel.

21
3.3 Study Area and Population

Burao It is the capital city of the Togdheer region in Somaliland it is the second largest

city in Somaliland after Hargeisa. Burao's population has greatly increased over the past

years. Today the city has a population more than 400,000 inhabitants. It has warm and

dry year round. The average daytime temperatures during the summer months of June

and August can rise to 35°C (95°F), with low of 25°C (77°F) at night. The weather is

cooler the rest of the year, averaging 27°C (80°F) during the day and 14°C (57°F) at

night time, has health facility centers such burco general ospital and other private

hospitals.

Figure 1; map of the study area

22
3.4 Sampling Techniques

The researcher further used random sampling as a technique for data collection. This

remained necessary whereby the selected sample at random was legible enough to

represent the study area chosen by the researcher. A total of 33 participants were

interviewed who were chosen randomly to represent the entire Burao population.

3.5 Data Collection Methods

Data was collected during a person-to-person interview administered questionnaire

between a study field worker and member of the designated village. Only those from the

selected village were able to be included in the study and only those were 16 years or

over, had lived in the village for a minimum of five years and consented. The field work

was conducted over a period of 7 weeks with between 3 to 5 days spent at each village

site.

Each participant had the study explained to them, the risks and benefits, and was then

given the opportunity to consent to participate. If participants were literate they were

required to sign and date an English and, a separate, Somali version of the consent

forms,. If subjects were illiterate they were required to be consented in front of a third

person, , to acknowledge that an accurate explanation was given to the participant who

had consented and was not coerced. The witness was required to be able to understand

the language used for this that is both English and Somali. Illiterate subjects who were

unable to make a mark were required to use a stamp pad to make an imprint of a finger

on the consent forms. Generally, the study group was set up around a building of some

type where the forms and other equipment could be kept and participants would wait

23
outside in a larger public area. When it was their turn they were walked off with one of

the field workers and sat down under a tree or in the shade of a building. Once subjects

had consented and had completed the questionnaire interview, the field worker brought

the participant to a central area to hand over the questionnaire to a study member where it

was numbered for the master list and stored. At this point the questionnaire was reviewed

by one of the study team for inaccuracies, questions missed or other problems that could

be resolved immediately. One hundred percent of the questionnaires were reviewed.

Interviews between field workers and participants were observed on an unarranged basis

and random post-interview discussions took place to point out issues, or review issues

with the questionnaires and also to motivate the field workers. Each morning and

afternoon during a group meeting, the day‟s activities were planned or reviewed and any

difficulties discussed.

3.6 Interpretation

All questionnaires were collected in a central location and reviewed against the

masterlist.Consent forms were paired with questionnaires. Any questionnaire that could

not be paired with its consent form or where the consent form was incorrectly completed

was destroyed. Software database was created. All inaccuracies were reviewed and

corrected using the original questionnaire of the participant. Data analysis was done using

SPSS soft ware.

24
 CHAPTER 4

DATA PRESENTATION AND ANALYSIS

4.1 Data presentation and Analysis

This chapter presents the results of the study and it is organized into three main sections:

background of the sample, and examination of the hypotheses, To examine the research

questions, descriptive statistics and frequencies were run using SPSS Version 23

Health care seeking behaviour is defined in its broadest terms (Ahmed et al., 2000) as

relating to health care access, service use, health outcomes and the way in which people

respond to their perceived ill health. Distinctions are made between formal and informal

settings and between private and public settings for seeking treatment. Participants are

asked about their preferences for seeking health care.

Background of the Sample

Total of (33) respondents were sampled in this study. 23 of them were members of the

community and they came from four villages which were: Shacab area, Afgoye, Tuurta

and Kenya. The other 10 respondents were health professionals who were sampled from

Burco General Hospital existing in Burao city. Part A of the questionnaire was filled by

members of the community while Part B was filled by the 10 health professionals. All the

33 copies of the questionnaire were distributed evenly among the respondents of these

villages and the health professionals using random sampling and were well completed

and returned.

25
4.2 Presentation of results

Results from the data collection and subsequent analysis of the variables considered will

be presented here. Results will be presented descriptively as numbers and percentages to

describe the population and variables of interest.

Community Findings

Gender

Of the 23community subjects enrolled, gender was male 8 (43.8%). While , 15 (65.2%)

were female. Some differences were noted based on village.as shown below

Gender of participant

Cumulative

Frequency Percent Valid Percent Percent

Valid Male 8 34.8 34.8 34.8

Female 15 65.2 65.2 100.0

Total 23 100.0 100.0

Table: Percentages of the Sample Population by Gender

Education

Overall, 6 (26.1%) reported university, 6 (26.1%) reported high school. 1 (4.3%) reported

primary,

10(43.5%) participants reported preschool as shown below

26
Education level

Cumulative

Frequency Percent Valid Percent Percent

Valid University 6 26.1 26.1 26.1

High school 6 26.1 26.1 52.2

Primary school 1 4.3 4.3 56.5

Preschool 10 43.5 43.5 100.0

Total 23 100.0 100.0

Table: Percentages of the sample population reported level of education

Marital status

This study an individual Interview was taken from the 33 community reprehensive

members randomly from burao population. 8 respondent out of 33 members (34.8 %),

mentioned they are single ,12 (52.2%) pointed out that they married,2 (8.7%)they are

divorced and 1(4.3%) mentioned widowed as shown below table.

Marital status

Cumulative

Frequency Percent Valid Percent Percent

Valid Single 8 34.8 34.8 34.8

Married 12 52.2 52.2 87.0

divorced 2 8.7 8.7 95.7

Widowed 1 4.3 4.3 100.0

Total 23 100.0 100.0

Table: Percentages of the sample population reported marital status

27
Age

The number of participants was rather evenly divided among the various age categories

with 7 (30.4%) being 20-39, 12 (52.2%) being 30-49 of age variable, 4 (17.4%) being 50-

59 age .Again, there were some differences in age distribution among villages.as shown

below

Age of Participants

Cumulative

Frequency Percent Valid Percent Percent

Valid 20-39 7 30.4 30.4 30.4

30-49 12 52.2 52.2 82.6

50-59 4 17.4 17.4 100.0

Total 23 100.0 100.0

Table: Distribution of participants per Age Category

Main occupation

10 respondents out of 33 members, n=10 (43.5) mentioned and pointed out that they had

business,n=5 respodent out of 33 members (21.7%) poitedout unemployement and n=8

(34.8%) piotedout had civel service. Aas shown below

28
 What is your main occupation?

Cumulative

Frequency Percent Valid Percent Percent

Valid Business 10 43.5 43.5 43.5

Unemployed 5 21.7 21.7 65.2

Civil service 8 34.8 34.8 100.0

Total 23 100.0 100.0

Table: Percentages of the sample population reported main occupation

Is this work paid?

23 community respondents out of 16 members (69.6%), staates the work was paid and 7

members (30.4%)mentioned unpaid., the overall prevelence of the rsults as shown in

below table

29
 Frequency Percentage Cumulative Percent

Valid Yes 16 69.6 69.6

No 7 30.4 100.0

Total 23 100.0

Table: Percentages of the Sample Population reported their work paid

Rooms for sleeping

11 respondent out of 23 members (47.8 %), mentioned 1-3 rooms used for sleeping,12

respodent out 23 (52.2%)mentioned 4 upto more rooms used sleeping.

How many rooms in your household are used for sleeping?

Cumulative

Frequency Percent Valid Percent Percent

Valid 1-3 Rooms 11 47.8 47.8 47.8

4 up to more rooms 12 52.2 52.2 100.0

Total 23 100.0 100.0

Table: percentages of sample population reported rooms used for sleeping

Current health

Question asked respondents how you would rate your current health. A frequency

analysis indicated that 8.7% (n=2) said they poor, 26.1 % (n=8) said they fair. And

65.2.4% (n=15) were excellent shown below:

30
 How would you rate your current health?

Cumulative

Frequency Percent Valid Percent Percent

Valid Poor 2 8.7 8.7 8.7

Fair 6 26.1 26.1 34.8

Excellent 15 65.2 65.2 100.0

Total 23 100.0 100.0

Table: Percentages of sample population reported by current health

Past Health

Question asked respondents “how would you rate your health in the past year?” A

frequency analysis indicated that 17.4% (n=4) were poor. 39.1% (n=9) said they fair and

said they agree. 43.5% (n=10) were excellent as shown below:

31
 How would you rate your health in the past year?

Frequency Percent Valid Percent Cumulative Percent

Valid Poor 4 17.4 17.4 17.4

Fair 9 39.1 39.1 56.5

Excellent 10 43.5 43.5 100.0

Total 23 100.0 100.0

Table: percentage of the sample population reported health in the past year

Illness

The question ask “has you been ill in the past 3 months?” 14 respondent out of 23

members (60.9. %), mentioned sick,7 repondent (30.4%) mentioned health and 2 (8.7%)

mentaioned do not known as shown table below.

Have you been ill in the past 3 months?

Frequency Percent Valid Percent Cumulative Percent

Valid Yes 14 60.9 60.9 60.9

No 7 30.4 30.4 91.3

Don't know 2 8.7 8.7 100.0

Total 23 100.0 100.0

Table: Numbers and Percentages of Respondents that Reported ill in the past 3 months

Causes

Question five asked respondents “Do you know what was making you ill?”. A frequency

analysis designated that 17.4% (n=4) were unknown, 13.0% (n=3) said they Diarrhoea,

8.7% (n=2), 34.8% respiratory infection and 26.1% (n=6) said other infection as shown

below.

32
 Do you know what was making you ill?

Cumulative

Frequency Percent Valid Percent Percent

Valid Don't know 4 17.4 17.4 17.4

Diarrhoea 3 13.0 13.0 30.4

Skin infections 2 8.7 8.7 39.1

Respiratory infection 8 34.8 34.8 73.9

Others 6 26.1 26.1 100.0

Total 23 100.0 100.0

Table: percentage of the sample population reported causative ill-health Seek

Seeking treatment

Question asked respondents “Did you seek any treatment?” A frequency analysis indicated

that 23 individuals in the burao district that reported where they would obtain their health

33
care, if they had a choice. Of these 2 (8.7%) would prefer to go to a MCH, 3 (13%)

would prefer a government hospital, 11 (47.8%) individuals would choose a private

clinic, 1 (4.3%) would choose treatment from a traditional treatment. As shown below

Did you seek any treatment?

Cumulative

Frequency Percent Valid Percent Percent

Valid Yes 17 73.9 73.9 73.9

No 6 26.1 26.1 100.0

Total 23 100.0 100.0

Table: percentage of the sample population reported Seek Treatment

34
 If the answer of the above question is yes, where did you seek treatment?

Frequency Percent Valid Percent Cumulative Percent

Valid MCH 2 8.7 11.8 11.8

Goverent hospital 3 13.0 17.6 29.4

Private clinic 11 47.8 64.7 94.1

Traditional healer 1 4.3 5.9 100.0

Total 17 73.9 100.0

Missing System 6 26.1

Total 23 100.0

Table: Individual of the household had a choice where would seek health care

Treatment

Question asked respondents “Were you able to get all the treatment you needed?” A

frequency analysis indicated that 73.9% (n=17) said yes and 26.1% (n=6) said No as

shown below:

Were you able to get all the treatment you needed?

Frequency Percent Valid Percent Cumulative Percent

Valid Yes 17 73.9 73.9 73.9

No 6 26.1 26.1 100.0

Total 23 100.0 100.0

Table: Numbers and percentages of the sample population by the travel time to nearest

35
Health Expenses

Question six asked respondents “What was the cost of diagnosis, treatment and other expense you expend

A frequency analysis indicated that 30.4% (n=7) said were paid 1-20 USD, and 69.6% (n=16) said were p

more 20 USD as shown below:

What was the cost of diagnosis, treatment and other expense you expend?

Cumulative

Frequency Percent Valid Percent Percent

Valid 1-20 7 30.4 30.4 30.4

20 upto more 16 69.6 69.6 100.0

Total 23 100.0 100.0

Table: percentage of the sample population reported by cost healthcare

36
Who paid?

Question asked respondents “Who is paid for your expense?” .A frequency analysis indicated

that 60.9% (n=14) said paid himself , 26.1% (n=6) said paid someone else in him

household, 4.3% (n=1) said paid for barrowed money, and 8.7% (n=2) said paid

someone else in outside household. As shown below:

Who is paid for your expense?

Cumulative

Frequency Percent Valid Percent Percent

Valid You 14 60.9 60.9 60.9

Someone else in your

6 26.1 26.1 87.0
household

Borrowed money 1 4.3 4.3 91.3

Someone else

outsidehousehold or 2 8.7 8.7 100.0

relatives

Total 23 100.0 100.0

Table: percentage of the sample population reported who paid expenses

37
Closest Health Facility

Twenty three (23) respondents answered this question. To create a dichotomous variable

a distinction was made between hospitals and health canters versus clinics. The level of

care and type of facilities are also distinctive.

What kind of health facility is the nearest to your house?

Cumulative

Frequency Percent Valid Percent Percent

Valid Hospital 3 13.0 13.0 13.0

Health center 10 43.5 43.5 56.5

Clinic 10 43.5 43.5 100.0

Total 23 100.0 100.0

Table: percentage of the sample population reported nearest health facility

Transportation

Transportation

Question asked respondents Which is the way you would normally get to this health

facility?. A frequency analysis indicated that 43.5.3% (n=19) mentioned they use foot,

39.1% (n=9) said they used a bus, 4.3% (n=) said a vehicle and 13.0% (n=3) said other

as shown below:

38
Which is the way you would normally get to this health facility?

Frequency Percent Valid Percent Cumulative Percent

Valid Foot 10 43.5 43.5 43.5

Bus 9 39.1 39.1 82.6

Vehicle 1 4.3 4.3 87.0

Other 3 13.0 13.0 100.0

Total 23 100.0 100.0

Table : percentage of the sample population reported the way get health facility

Travel Time

Respondents were asked how long it would take for them to travel to the nearest health

facility using the means of transport they would normally use. Twenty three (23)

community respondents answered. These categories were divided into another

dichotomous variable indicating if it took respondents more or less than one hour to get

to the nearest health facility.

39
 How long does it take to get to this healthy facility?

Cumulative

Frequency Percent Valid Percent Percent

Valid Less than 15 minutes 5 21.7 21.7 21.7

Between 15 and 30 minutes 4 17.4 17.4 39.1

Between 30 and 1 hour 7 30.4 30.4 69.6

Between 1 hour and 2 hours 7 30.4 30.4 100.0

Total 23 100.0 100.0

Table: numbers and percentages of the sample population by travel time to the nearest

Common illness

Question asked respondents “What do you think are the most common illness in this

area?. A frequency analysis indicated that 13% (n=3) said were unknown, 21.7% (n=7)

said malaria,. 8.7% (n=2) were Diarrhoea, 30.4% (n=7) said were common cold, 8.7%

(n=2) said were skin infection,17.4%(n=4) said respiratory infection as shown below:

40
 What do you think are the most common illness in this area?

Cumulative

Frequency Percent Valid Percent Percent

Valid Don't know 3 13.0 13.0 13.0

Malaria 5 21.7 21.7 34.8

Diarrhoea 2 8.7 8.7 43.5

Common cold 7 30.4 30.4 73.9

Skin infections 2 8.7 8.7 82.6

Respiratory infection 4 17.4 17.4 100.0

Total 23 100.0 100.0

Professional Findings

This part of the questionnaire was answered by 10 health professionals and the questions

and analyses include the following:

Question one asked the health professionals whether they have a special department that

deals with health care services in their hospital issues

Professional tittle

Professional title A frequency analysis indicated that 50.0% (n=5) doctors, 30.0% (n= 3)

Nurse, 10.0% ,Administration (n=1),and 110% (n=1) Secretory n=1 (10%)as shown below

41
 Professional title

Cumulative

Frequency Percent Valid Percent Percent

Valid Doctor 5 50.0 50.0 50.0

Nurse 3 30.0 30.0 80.0

Administration 1 10.0 10.0 90.0

Secretory 1 10.0 10.0 100.0

Total 10 100.0 100.0

Table : percentage of the sample by health professional

The question asked respondents “what are the main factors that facing the utilization of

health service in your society? A frequency analysis indicated that 10% (n=1) said lack of

specialist, 50% (n=5) said economic factor, 30% (n=3) said poor health organizations

while 10% (n=1) said communication barriers as shown below

What the main factors that facing the utilization of health service in your socity?

Cumulative

Frequency Percent Valid Percent Percent

Valid Lack of specialist doctors 1 10.0 10.0 10.0

Economic factor 5 50.0 50.0 60.0

Poor health organizations

3 30.0 30.0 90.0
activities

Communication barriars 1 10.0 10.0 100.0

Total 10 100.0 100.0

42
The question asked respondents “how do you think should be done to resolve these

factors that influence in your society?” A frequency analysis indicated that 40% (n=4)

said earn health specialist, 30% (n=3) said earn latest surgical equipment, 20% (n=2) said

earn hospital each district,10% (n=1) said income generation as shown below

43
 How do ou think should be done to resolve these factors that influence in your society?

Cumulative

Frequency Percent Valid Percent Percent

Valid Earn health specialist 4 40.0 40.0 40.0

Earn latest surgical

3 30.0 30.0 70.0
equipment

Earn hospitals each district 2 20.0 20.0 90.0

Income generation 1 10.0 10.0 100.0

Total 10 100.0 100.0

The question asked respondents “what sre the most problems that you would manage?”.

A frequency analysis indicated that 60.0% (n=6) saidaccidents,20% (n=2) said early

pregnancy and 20.0% (n=2) said infectious disease as shown below

44
 What are the most problems that you would manage?

Cumulative

Frequency Percent Valid Percent Percent

Valid Accidents 6 60.0 60.0 60.0

Early pregnancy 2 20.0 20.0 80.0

Infectious disease 2 20.0 20.0 100.0

Total 10 100.0 100.0

The question asked respondents “how many cases do you referred per month?”. A

frequency analysis indicated that 60.0% (n=6) said 1=10 case while40.0% (n=4) said

referred 10-20 cases as shown below.

45
 How many cases do you referred per month?

Cumulative

Frequency Percent Valid Percent Percent

Valid 1-10 6 60.0 60.0 60.0

10-20 4 40.0 40.0 100.0

Total 10 100.0 100.0

Referral

Six (6) respondents answered this Professional question. To create a dichotomous

variable a distinction was made between referral areas. As shown

46
 Where did you refer it?

Cumulative

Frequency Percent Valid Percent Percent

Valid Hargeisa 6 60.0 60.0 60.0

Ethiopia 2 20.0 20.0 80.0

Malaysia 1 10.0 10.0 90.0

India 1 10.0 10.0 100.0

Total 10 100.0 100.0

47
Conclusion

This chapter offered the data results and presented the analyses generated by the SPSS

computer software. Basing on the results, widely held of respondents agreed that they

possess barrier that influence of health care service but it is minimally get rid among the

community members, and most responsible due to the Government and NGO dealing

with.

The following chapter will summarize the study and present conclusions about the

findings of the study and future recommendations for continued research in this issue.

48
 CHAPTER 5

SUMMARY AND RECOMMENDATIONS

5.1 Summary of findings

The findings of the information gathered show many similarities across the survey

population. Over four villages burao district, women were more likely than men to seek

formal health care treatment. Participants that were illiterate were more likely to use and

choose formal health care services, while those that were literate and had formal

education were more likely to use and prefer formal health care services for a member of

their household, but use and prefer private health care for themselves. The older the

participant, the less likely they were to choose formal health care services. If participants

had regular income a member of their household was more likely to seek treatment and

prefer formal and private health care. Having access to communications meant that

members of the household were more likely to seek treatment,. The majority of

respondents that sought treatment lived closest to a smaller health care facility, while

people that lived farthest from a hospital or health center preferred informal services.

Close to half of the respondents had a time when they were unable to reach the nearest

health facility, but this was not specific to formal or informal, private or public health

care services. Respondents that stated they would prefer formal over informal, or private

over public, were all more likely to have a time when they or a member of their

household, had been unable to reach a facility or receive treatment.

49
There were also some differences in the results between each of the villages which had as

much to do with the resources and services available, as it did the sociodemographic

aspects of the community members themselves. Respondents from the afgooye vilaage

more often sought treatment than those from the october or jarmal vilage. In the Busia

district those that had access to communications were more likely to receive treatment.

Those with no regular income would prefer formal and private health care services.

Respondents were more likely to live within 60 minutes travel time of a health care

facility and less likely to live nearest a hospital or health centre. Respondents from the

Burao district were more likely to report a time they had be enunable to reach the nearest

health care facility. Those respondents who were from the district were more likely to

have formal education and prefer private health care. Residents from the villages that did

not have regular income would prefer formal health care services, although those without

regular income were less likely to receive all the treatment they needed.

5.2 Discussion of findings

There are many factors that influence health and health care services. Although many of

these factors are similar across populations, exactly how they interact and influence the

actions of people is often exclusive to a population in the context of the environment they

live in. The current study, a population-based cross sectional survey, identifies 4 specific

villages‟ populations in burao city of Somaliland, to gain information regarding overall

influences on health care seeking, and also information specific to each area to directly

target the health needs of the individual population living there. Participants of the survey

were interviewed for personal information and details regarding their activities in

response to their health and ill-health. The subsequent data was then analyzed to

50
determine which factors affected the use of health and medical services within the study

areas and whether the study participants believed their health needs were being met. Just

over half the population surveyed had been sick and sought treatment, of these between

73.9% used formal health care services over informal services with more preferring

formal if they had the choice. There were some differences according to gender,

education of respondents, while other factors such as the costs associated with seeking

treatment, distance and time taken to travel also affected health care service use. Barriers

to respondents receiving treatment included financial and physical access issues however;

although this more than half the population that sought treatment believed their health

needs were being met.

5.3 Recommendations based on findings

Based on the present findings and analysis, the following recommendations are aimed at

improving factors that influence health care service for Hospital and MCH. I

recommended the following:

Interventions should be directed at enhancing providers' understanding of how to

work effectively with people with patient or outpatient.

Linking of rehabilitation specialists as consultants to group practices or

community clinics should be done so that the physicians‟ expertise would be

available to primary care providers in community settings.

Provisions of timely access to treatment.

Making MCH and clinics available in all villages so that long distances will not

become a major factor preventing people who cannot walk from accessing health

care services.

51
 To generate specialists‟ expertise in order to intensification health care

To increase quality of medications and health providers in both hospital and

MCH

To date, the Ministry of Health has built clinics, provided health care providers and

medications, and also has introduced free access to health care services for people with

low income and a lot more but there are still those critical factors related to the needs of

those with physical impairments that the Ministry still needs to consider.

52
APPENDICES

Appendix A: Community Questionnaire

THIS BELLOW QUESTIONNAIRE ON THE FACTORS THAT INFLUENCE

UTILIZATIONS OF HEALTH CARE SERVICE IN HOSPITAL AND MCH

Dear respondent:

My name is Mustafe Hashi Ibrahim Hussein. I am a student at GOLLIS University,

Burao Campus pursuing a Bachelor‟s Degree in Clinical Medicine. As an academic

requirement, I am collecting data for my graduation research paper by looking On the

Factors That Influence Utilizations of Health Care Service in Hospital and MCH Any

information that you shall provide herein shall be specifically for academic purposes and

shall be handled confidently without being released to any other person.

Please if you met any difficulty about the questionnaires‟ do not hesitate to let me know

and if you don‟t want to respondent let me know it and say I don‟t have more

information and we will go ahead to the next question

Thanks for your cooperation.’

Kindly answer the following questions by choosing the right answer and writing

correctly where necessary. Your answers should be based on your own understanding

without any other person’s influence.

SECTION A: GENERAL INFORMATION

53
Participant Name: _______________________________________ Address:

__________

Age of respondent

-29 -39 30-49 -59

Gender

Marital status

Widowed

Education Level: -school

(Quran)

Occupation: ____________________Jobless: _______________________

Please list the people in your house_________ Boys _________________

Girls______________

What age of youngest child? _________

Socio economic and Health Information

1. What is your main occupation?

Other

2. Is this work paid?

54
3. What do you normally spend the most money on?

Please tick in order of most money spent .

Food

Clothing

Rent

Healthcare

Education

Transport

Others

4. How many rooms in your household are used for sleeping?

________________________________________________________________________

________________________________________________________________________

____________

5. How would you rate your current health?

Poor Fair Excellent

6. How would you rate your health in the past year?

poor Fair Excellent

7. Have you been ill in the past 3 months?

55
 Yes No Don't know

8. Do you know what was making you ill?

Don‟t now

Diarrhoea

Skin infections

Respiratory infection

Others

9. Did you seek any treatment?

10. If the answer of the above question yes, where did you seek treatment?

MCH Goverent hospital Private clinic Traditional healer

Other

11. Were you able to get all the treatment you needed?

Yes No

If no, why not?

_______________________________________________________________

12. What was the cost of the diagnoses, treatment and other expense you expend?

________________________________________________________________________

13. Who is paid for your expense?

You

Someone else in your household

56
 Borrowed money

Someone else outside household or reatives

14. What kind of health facility is the nearest to your house?

Hospital Health center Clinic

15. Which is the way you would normally get to this health facility?

16. How long does it take to get to this health facility?

17. What do you think are the most common illnesses in this area?

[you can select more than one ]

Don't know Malaria Diarrhoea Skin disease

Common cod Respiratory infection Urinary tract infection
.

18. What is your biggest concern about your health and the health of those in your

household?

………………………………………………………………………………………………

………………………………………………………………………………………………

………………

19. If you have any further comments please use the space provided here.

57
Appendix B: Professional questionnaire

THIS BELLOW QUESTIONNAIRE ON THE FACTORS THAT INFLUENCE

UTILIZATIONS OF HEALTH CARE SERVICE IN HOSPITAL AND MCH

Dear respondent:

My name is Mustafe Hashi Ibrahim Hussein. I am a student at GOLLIS University,

Burao Campus pursuing a Bachelor‟s Degree in Clinical Medicine. As an academic

requirement, I am collecting data for my graduation research paper by looking ON THE

FACTORS THAT INFLUENCE UTILIZATIONS OF HEALTH CARE SERVICE IN

HOSPITAL AND MCH Any information that you shall provide herein shall be

specifically for academic purposes and shall be handled confidently without being

released to any other person.

Please if you met any difficulty about the questionnaires‟ do not hesitate to let me know

and if you don‟t want to respondent let me know it and say I don‟t have more

information and we will go ahead to the next question

Thanks for your cooperation.’

Kindly answer the following questions by choosing the right answer and writing

correctly where necessary. Your answers should be based on your own understanding

without any other person’s influence.

PROFESSIONAL QUESTIONAIRE

Only answered by health professional

58
Name

(optional):____________________________________________________________

Health Centre:

________________________________________________________________

Title:

_______________________________________________________________________

1. What the main factors that facing the utilization of health services in your society?

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

__________________

2. How do you think should be done to resolve those factors that influence in your

society?

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_________________

3. What are the most problems that you will manage?

_____________________________________________________________________

_____________________________________________________________________

59
 _____________________________________________________________________

_____________________________________________________________________

4. How many cases you do transfer per month?

1-10 10-20 20-30

30-40

5. Where you transfer it?

Hargeisa Ethoipia India Malaysia

Thank you for completing this questionnaire

60
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