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Available online at www.sciencedirect.com

Public Health

journal homepage: www.elsevier.com/puhe

Review Paper

Health-seeking behaviour in Pakistan: A narrative review

of the existing literature

M. Anwar*, J. Green, P. Norris

School of Pharmacy, University of Otago, PO Box 56, Dunedin 9054, New Zealand

article info summary

Article history: Introduction: This narrative review was carried out to collate the work of researchers on
Received 9 May 2011 health-seeking behaviour in Pakistan, to discuss the methods used, highlight the emerging
Received in revised form themes and identify areas that have yet to be studied.
11 November 2011 Study design: Review.
Accepted 9 February 2012 Methods: An overview of studies on health-seeking behaviour in Pakistan, found via
Available online 10 May 2012 searches on scholarly databases intended to locate material of medical and anthropolog-
ical relevance.
Keywords: Results: In total, 29 articles were reviewed with a range of different methodologies. A
Health-seeking behaviour retrospective approach was the most common. A variety of medical conditions have been
Pakistan studied in terms of health-seeking behaviour of people experiencing such conditions.
Retrospective approach However, a wide range of chronic illnesses have yet to be studied. Nevertheless, some
Traditional healers studies highlighting unusual issues such as snake bites and health-seeking behaviour of
Superstitions street children were also found. In terms of geographical area, the majority of studies
Self-medication reviewed were performed in the provinces of Sind and Punjab, with little research targeting
the people from the two other provinces (Balochistan and Khyber Pakhtunkhwa) of
Pakistan. Predominant utilization of private healthcare facilities, self-medication,
involvement of traditional healers in the healthcare system, women’s autonomy, and
superstitions and fallacies associated with health-seeking behaviour were found to be the
themes that repeatedly emerged in the literature reviewed.
Conclusions: The sociocultural and religious background of Pakistan means that health-
seeking behaviour resembles a mosaic. There is a need to improve the quality of service
provided by the public healthcare sector and the recruitment of female staff. Traditional
healers should be trained and integrated into the mainstream to provide adequate
healthcare. Serious efforts are required to increase the awareness and educational level of
the public, especially women in rural areas, in order to fight against myths and supersti-
tions associated with health-seeking behaviour.
ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Introduction developing countries. Illness behaviour (a similar term to

health-seeking behaviour) was defined by Mechanic1 as the
Health-seeking behaviour has drawn considerable attention manner in which individuals monitor their bodies, define
from researchers in recent years, especially in the context of and interpret their symptoms, take remedial action, and

* Corresponding author. Tel.: þ64 3 4797321; fax: þ64 3 4797034.

E-mail address: [email protected] (M. Anwar).
0033-3506/$ e see front matter ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.puhe.2012.02.006
508 p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) 5 0 7 e5 1 7

utilize other sources of help, as well as engage with the

more formal healthcare system. It is also concerned with Aim and objectives of the review
how people monitor and respond to symptoms and
symptom change over the course of an illness, and how it The dearth of data on health-seeking behaviour in Pakistan
affects the behaviour, remedial actions taken and response drew the authors to search for and review the existing liter-
to treatment. Researchers have used other related terms in ature. As the articles pertaining to the aforementioned issue
literature such as pain behaviour, health behaviour, sick- are contained in different journals and databases, some of
role behaviour and care-seeking behaviour,2e4 but all focus which are not easily accessible, especially to international
on the same issue: people’s response to illness. Numerous readers, the aim of this review was to collate the work of all
studies have been carried out all over the world in different researchers and bring it to the attention of readers. The
sociocultural settings,4e8 including considerable work in specific objectives were: (i) to document the range of meth-
South Asia.9e12 odologies used to perform such studies; (ii) to highlight the
Pakistan is the second largest South Asian country with emerging themes which were prominent and found to occur
a population of 169.7 million (2009 estimate),13 making it the repeatedly in the literature; (iii) to list the medical conditions
sixth most densely populated country in the world. However, for which health-seeking behaviours have been studied; (iv) to
in terms of human development, it is ranked 125th among 169 identify the geographical areas and target groups that are
countries.14 Although Pakistan’s Human Development Index neglected in this research in Pakistan; and (v) to make
(HDI) has improved from 0.346 in 1975 to 0.490 in 2010, this recommendations for future work.
improvement has been slow.14,15 The health system in
Pakistan consists of public and private sectors.16 The Ministry
of Health (MOH) at the federal level develops national policies Locating the relevant literature
and strategies for the entire population of the country, espe-
cially those who are under-served, and sets national goals and As the topic is of medical as well as anthropological relevance,
objectives, including for maternal healthcare.15 The public multiple databases were used, namely PubMed, Academic
sector encompasses a wide network of dispensaries, basic Search Complete (via Ebsco), Social Sciences Citation Index,
health units, rural health centres and hospitals. However, in and Scopus. A number of relevant terms and combinations of
the private sector, apart from some accredited outlets and terms were used to search for the literature, such as ‘health
hospitals, there is mushrooming growth of medical general seeking behaviour in Pakistan’, ‘health beliefs in Pakistan’,
practitioners, homoeopaths, traditional/spiritual healers, ‘illness behaviour in Pakistan’ and ‘response to illness in
GrecoeArab healers, herbalists, bonesetters and quacks.17 Pakistan’. In addition, papers cited in the reference lists of
This may lead to inappropriate or delayed healthcare result- relevant papers were retrieved. In total, 31 articles including
ing in undesirable outcomes. one letter published between 1980 and 2010 were found to be
Despite an elaborate and extensive network of health relevant to the notion of health-seeking behaviour in Pakistan.
infrastructure, especially in the public sector, the healthcare One study was presented in full as one publication,23 with two
delivery system in Pakistan has failed to bring about further publications17,24 found to be merely the elaboration of
improvement in health status, especially of rural populations. certain parts of the main study; in this case, the three publi-
The health system is characterized by inadequate expendi- cations were considered as one research study. Thus, the total
ture, poor quality services, and poor access to and utilization number of studies included in this narrative review was
of services.15 The life expectancy stands at 67 years, with reduced to 29. The majority of the articles included in this
a high infant mortality rate of 72/1000 live births14,18 and review were published in the Journal of Pakistan Medical Asso-
a maternal mortality rate of 320/100,000 live births.14,15 Non- ciation; all issues since 2001 are available online. Five of the
communicable diseases represent a major and rapidly- articles of interest were published before 2001 and were not
growing problem in Pakistan.19 available online, so the Editor kindly scanned and sent the
The Government of Pakistan spends 2% of its gross requested articles. A brief description of studies involved in
domestic product on healthcare (2006 estimate)13 which, the review is given in Table 1.
while increased from 0.8% in 1998/1999, is still lower than
other South Asian countries such as Bangladesh (3.2% in
2006).20,21 However in the 2009e10 budget, the health sector Methodological issues
was marked by six policy highlights, one of which is ‘scale up
of existing budget’.22 An increase in the budget for the As evident from Table 1, a range of different methodologies
healthcare system might improve the overall healthcare have been used to gather data on health-seeking behaviour.
delivery system in Pakistan. However, policy making for the However, the majority of researchers have used semi-
healthcare system must also be informed by information structured or structured interview approaches to conduct
relating to health-seeking and utilization behaviour and the studies. Kroeger argued that this is the best remedy for
factors affecting these behaviours, in order for the policies to minimizing interviewer influences.25 Moreover, such an
be more evidence-based, realistic and beneficial. Unfortu- approach provides freedom to the interviewees and an
nately, literature pertaining to these topics in Pakistan is opportunity to discuss their experiences and perceptions in
generally lacking, which could be one of the reasons why greater depth. Interviews typically require participants to
health policies have not been translated into improvements in recall their past experiences, and so these may be susceptible
healthcare. to errors in recall and social desirability biases. However, in
Table 1 e Description of the studies included in the review.
Study Type Participants Focus/illness Study design Geographical area: province
(village/town/city)

Hasan67 (1981) Hospital based Patients in general wards Multiple conditions Cross-sectional, qualitative Punjab (Lahore)
of a public hospital (205) structured interviews
Mull and Mull81 (1988) Community based Mothers (57) Childhood diarrhoea Cross-sectional, qualitative Sind (45 villages around the town
structured interviews of Vur)
Hunte and Sultana68 (1992) Community based 65 households (18 mothers; General Cross-sectional, in-depth Balochistan (two villages)
23 children) interviews
Kundi et al.79 (1993) Clinic based Mothers (50) Childhood pneumonia Cross-sectional, in-depth Punjab (Rawalpindi)
interviews
Mull and Mull34 (1994) Community based Mothers and Childhood pneumonia Cross-sectional, in-depth (i) Sind (squatter settlement
grandmothers (35) interviews of Karachi)
(ii) Punjab (rural areas)
Haider and Thaver69 (1995) Community based 150 households Self-treatment for children Cross-sectional, quantitative Sind (slum and non-slum areas
(158 mothers) structured interviewse of Karachi)
Zahid86 (1996)a

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e e e e e
Bhatti et al.72 (1999) Clinic and Married women (17) Infertility Cross-sectional, in-depth Sind (squatter settlement
community-based interviews of Karachi)
Hasan and Khanum58 (2000) Community based Mothers of 259 infants Terminal child illness Cross-sectional, qualitative Sind (squatter settlement
who had died structured interviews of Karachi)
Khan et al.97 (2000) Community based Patients (36) Pulmonary tuberculosis Cross-sectional, in-depth Punjab (Sahiwal, Rawalpindi and
interviews Gujranwala)
Chandio et al.41 (2000) Community based Inflicted public (200) Snake bite Cross-sectional, quantitative Sind (Hala, Khairpur, Maro,
structured interviews Pano-Aaqil, Sukkur and Umerkot)
Sadiq and de Muynck70 (2001) Hospital based Patients (160) Pulmonary tuberculosis Cross-sectional, quantitative Punjab (Rawalpindi)
structured interviews
Fatmi and Avan59 (2002) Community based Married women (222) Antenatal care Cross-sectional, quantitative Sind (rural areas of district Dadu)
structured interviews
Bhatti and Fikri42 (2002) Clinic based Married women (18) Reproductive tract infections Cross-sectional, in-depth Sind (squatter settlement
interviews of Karachi)
Mahmood and Ali35 (2002)b e e e e e
Bukhari et al.45 (2002) Community based People from varied Superstitions Cross-sectional, quantitative Sind (areas of Karachi representing
ethnic groups (100) structured interviews varied ethnic groups)
D’Souza80 (2003) Community based Mothers (222) Childhood diarrhoea and acute Cross-sectional caseecontrol Sind (slums of Karachi)
respiratory tract infections study, quantitative structured
interviews
Rao and Soomro66 (2004) Community based General public (600) Use of local pharmacy in Cross-sectional, quantitative Sind (urban and semi-urban areas
treatment seeking structured interviews of Karachi)
Shaikh and Hatcher82 (2004) e e A discussion on factors affecting e e
health-seeking behaviour in
Pakistan
Ali and de Muynck71 (2005) Community based Street children (57) General Cross-sectional, in-depth Punjab (Rawalpindi)
interviews
and FGD
(continued on next page)

509
 510
Table 1 e (continued )
Study Type Participants Focus/illness Study design Geographical area: province
(village/town/city)

Qureshi and Shaikh87 (2006) e e Myths and misconceptions e e

affecting health-seeking
behaviour in Pakistan
Ali et al.43 (2006) Community based General public (200) Psychiatric illness Cross-sectional, self-administered Sind (five districts of Karachi)
questionnaire
Jafri et al.98 (2007) Clinic based General public (1048) IBS Cross-sectional, self-administered (i) Sind (suburban and urban areas
questionnaire of Karachi)
(ii) Punjab (suburban and urban
areas of Bahawalpur)
Shaikh et al.23 (2008) Community and General public, General Cross-sectional, in-depth Gilgit-Baltistan (Ghizar district)c
clinic based healthcare providers interviews and FGD
Qureshi et al.85 (2008) Clinic based Patients (301) Delays in health-seeking Cross-sectional, quantitative Punjab (Multan and Sialkot)
for tuberculosis structured interviews
Manzoor et al.57 (2009)

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Community based Postgraduate students General Cross-sectional, self-administered Federal territory (Islamabad)
questionnaire
Ladha et al.38 (2009) Community based Elderly population with General Cross-sectional, quantitative Sind (urban community of Karachi)
diabetes or hypertension structured interviews
Hussain et al.26 (2010) Community based Households (1346) General Longitudinal (10 weeks), (i) Punjab (Rawalpindi and adjacent
observational using structured rural areas)
questionnaire (ii) KPK (Abbotabad and Peshawar
including adjacent rural areas)
(iii) Islamabad and adjacent rural
areas
Mushtaq et al.73 (2010) Community based General public (1080) Pulmonary tuberculosis Cross-sectional, quantitative Punjab (60 villages in two districts)
semi-structured interviews

FGD, focus group discussion; IBS, irritable bowel syndrome; KPK, Khyber Pakhtunkhwa, previously known as NortheWest Frontier Province.
a Based on Pakistan demographic and health survey.
b Based on a socio-economic survey of Pakistan.
c A remote area situated 9000 feet above sea level.
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a recent study, Hussain et al. used a prospective approach by women because high fertility, maternal morbidity and infant
following up households weekly for a period of 10 weeks, and mortality rates are some of the important challenges currently
maintaining the records of all health disorders occurring faced by Pakistan.30 Five of the studies pertaining to childhood
during that period as well as the action taken by the family conditions gathered information mainly from mothers, but in
members.26 Such an approach may not only produce more paternalistic societies like Pakistan, where ‘group manage-
reliable results but may also help to observe the development ment of therapy’ and ‘familism’ are dominant features,31,32
of the outcome in question (in this case, health-seeking family interviews are more appropriate than individual
behaviour, which may develop or change with the passage interviews, especially in rural areas.32,33 One such study
of time and may be affected by events that occur during the interviewed not only the mothers but also the grandmothers
course of study). of the children.34 One study also used a large sample from
A handful of studies strived to document the perceived and a socio-economic survey of Pakistan35; however, it focused
intended health-seeking behaviour of the general public when mainly on disease incidence and prevalence, and utilization of
they acquire a certain condition. The problem inherent in healthcare services. This offers a valuable cross-sectional
using such an approach is that the actual health-seeking snapshot but cannot consider the determinants of health-
behaviour when one is ‘sick’ might be totally different from care seeking. It is therefore suggested that such surveys at
anticipated behaviour. a government level should also endeavour to investigate
Another methodological issue that is worth discussing at factors affecting health-seeking behaviour in order to better
this point, as it is linked with the retrospective approach, is understand the complex phenomenon of health-seeking
the influence of the recall period (recall of symptoms and behaviour.
use of care). When using retrospective questioning, a recall The importance of community-based surveys cannot be
period that gives the reliable information must be adopted. denied. The pitfall associated with the studies which
Unfortunately, most of the studies that used a retrospective captured the participants at healthcare facilities is that they
approach did not define a recall period, and this reduces the rule out those who do not or only rarely utilize any formal
reliability of their findings. Recall periods for illness healthcare facility, who may instead rely on either home
reporting as long as 12 months or more have traditionally remedies and/or the informal healthcare sector. Neverthe-
been used, particularly in developing countries, but are no less, such studies capture some very useful information on
longer thought to be sufficiently reliable to provide useful health-seeking behaviour of those who attend the formal
information.27 Minor complaints can even be under- healthcare setting. Shaikh and Hatcher, in their study on the
reported in a 2-week recall period.28,29 This further health-seeking behaviour of people from a remote area of the
suggests that the use of a prospective longitudinal approach northern province, have tried to minimize the problem by not
or using a short recall period would produce better data. only targeting the attendants of a formal healthcare setting
One of the most holistic approaches in this regard was but also running a community-based survey and interview-
designed by Kroeger in order to analyse and interpret ing healthcare providers from both formal and informal
factors and determinants of health-seeking behaviours and settings.36 Although certain researchers have documented
health services utilization, particularly in developing coun- reasons for preferring informal healthcare services over
tries.25 Only one study tried to apply a similar approach in formal services, the validity of such studies could be
a Pakistani setting, whereby the researchers not only used improved if the informal health service providers are also
variant survey techniques (interviews and focus group surveyed and information is gathered from those that use
discussions) but also captured the views of all the stake- such services.
holders including community (utilizers/non-utilizers of The elderly constitute 5.6% of the total Pakistani pop-
healthcare services), utilizers of healthcare services (exit ulation and the proportion will increase to 11% by 2025.37
interviews), and public and private healthcare service However, only one study was found that focused on the
providers (government, private formal and non-formal).23 health-seeking behaviour of the elderly in a poor urban
This study was carried out in a remote area of Khyber community of Karachi.38 Further in-depth studies are
Pakhtunkhwa (the northern province), so similar studies required to investigate the health-seeking behaviour of this
using a prospective approach and utilizing mixed method- considerable portion of the population.
ology, including qualitative and quantitative enquiry, could Several investigations have emphasized hypertension and
be performed in other parts of the country in order to draw diabetes as major public health problems in developing
a more comprehensive picture. nations,39,40 yet very little has been done in Pakistan on
health-seeking behaviour pertaining to such conditions and
other chronic ailments such as asthma, cancer, rheumatoid
Participants and medical conditions covered arthritis, depression and psoriasis. Researchers should also
explore the areas such as sexually transmitted infections,
A wide variety of disease states have been covered in the human immunodeficiency virus/acquired immunodeficiency
surveys of health-seeking behaviour in Pakistan, from infer- syndrome and social and cultural taboos associated with
tility to antenatal care, from reproductive tract infections in these conditions. Nevertheless, some unusual and interesting
females to certain childhood conditions, from snake bites to studies such as on snake bite,41 infertility,42 and health-
psychiatric ailments, and from irritable bowel syndrome to seeking behaviour of street children43 clearly show the quest
pulmonary tuberculosis. More attention has been paid to of researchers to explore variant conditions and target
childhood conditions and afflictions and experiences of different groups in the population.
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Tharparkar district, which has the lowest human develop-

Coverage of geographical areas ment index among all the districts of Sind.
Karachi is sometimes referred to as ‘mini Pakistan’ as it
Pakistan presents a range of different cultures and a variety of provides shelter to people from nearly all the ethnic groups in
languages, predominantly in rural and remote areas of all the Pakistan. A noteworthy study by Bukhari et al. investigated the
provinces. More than two-thirds of the population reside in health beliefs and superstitions associated with the overall
rural areas,24 where poverty is more prevalent, deeper and healthcare scenario among different ethnic groups residing in
more severe than in urban areas. People from rural areas in Karachi.45 This study provides baseline information that can
Pakistan are mainly engaged in agriculture, informal business, be further interlinked with the findings of similar studies
casual business or taking care of livestock, and have minimal performed in other parts of the country in order to present
access to quality education and healthcare.44 Conditions are a clearer picture of the overall complex phenomenon of
even worse in desert zones and in mountainous areas. health-seeking behaviour in Pakistan.
Fig. 1 shows a map of Pakistan and geographical areas A considerable number of studies have also been con-
covered by the studies reviewed. Most studies on health- ducted in Punjab province, ranging from rural to urban areas
seeking behaviour focused on Sind province. Of these, the and from northern to southern parts. However, Punjab, being
majority of studies focused on the squatter, urban or semi- the most populous province, still has many areas and pop-
urban areas of the provincial capital Karachi, the largest and ulation groups that have yet to be studied. Detailed research
the most populous city of Pakistan. Some research was also has been carried out in the remote areas of the Gilgit-Baltistan
conducted in other areas of Sind, focussing on the rural areas, region.23 However, only one such project has been carried out
but much remains unknown about the behaviour of people in in each of the Balochistan and Khyber Pakhtunkhwa areas,
other cities, towns and rural areas. Although the majority of and none of the research focused on the people of the Feder-
the population in Pakistan is Muslim, Sind is the home of ally Administered Tribal Areas (FATA) and Azad Jammu and
nearly all the Hindus in Pakistan, and they represent Kashmir. Only two studies conducted in the federal territory
a considerable proportion of the total population of Sind. (Islamabad) could be identified, one of which investigated the
Research should investigate the effects of religion and culture intended health-seeking behaviour of postgraduate students.
on such behaviour, and on the attitudes and illness behaviour The other study was important as it employed a longitudinal
in this area. Another focus should be the residents of approach and targeted households.26 More studies should be

Fig. 1 e Coverage of geographical areas in the studies reviewed.  Represents a study. Total number does not equal the total
number of studies as certain studies focused on more than one area.
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focused on the health-seeking behaviour of the people these services despite the fact that such services are subsi-
residing in modern cities like Islamabad, and the findings can dized by the Government.
be compared with those from other cities and rural parts of
the country in order to see the differences and similarities in Self-medication
the behaviours and the factors affecting these behaviours of
people from different socio-economic backgrounds. However, Self-medication is the selection and use of medicines
such efforts to conduct research in different areas of Pakistan (including herbal and traditional remedies) by individuals to
would require diverse language skills as well as in-depth treat self-recognized illnesses or symptoms.60 It is an ambig-
understanding of the indigenous culture. Being strongly con- uous phenomenon as, for some observers, it is a reason for
nected with their own unique cultures and having strong optimism: ‘a new attitude toward health, including increased
beliefs in their own traditions, people from remote areas of self-responsibility for health’,61 while other observers see
Pakistan might present interesting findings if engaged in such a darker picture of irrational self-medication and avoidance of
research. Nevertheless, engaging these people in research proper medical care. Self-medication is a common practice in
may prove to be an uphill task due to certain cultural and both industrialized and developing countries, but is hardly
traditional barriers. equivalent qualitatively or quantitatively.62 In economically
deprived communities, most illness episodes are treated by
self-medication.63,64 One of the most prominent factors that
Emerging themes promotes the practice of self-medication is ‘drug retail shops’
being the public’s first point of contact with the healthcare
Private healthcare facilities preferred over public facilities system.65 Such practices are very common in Pakistan but are
rarely documented. In Pakistan, almost every drug is sold as
Private healthcare provision is growing in low- and middle- an over-the-counter remedy. Rao and Soomro, in their study
income countries.46,47 Health services in the public sector on the role of the local pharmacy in health-seeking behaviour,
have always been under-utilized in developing countries,36 quote the reasons stated by people for using the local phar-
and general statements on the low quality of modern health, macy as the first point in their health-seeking quest.66 These
especially in rural areas, of developing countries are reasons included higher cost of treatment, extra fee to be paid
frequent.25 The reasons cited for using private healthcare by to the doctors, long waiting time, lack of 24-h availability of
users from different developing countries include better and doctors, common practice in society, doctors’ knowledge not
more flexible access, shorter waiting times, greater confiden- being up to the standard, self-confidence about knowledge of
tiality and greater sensitivity to user needs.46e50 However, the medicine, and pharmacists being a more up-to-date source of
quality of services offered by many private providers is poor,51 knowledge about drugs. However, the last reason holds some
and their responsiveness and discipline has been question- ambiguity as only a few reputable pharmacy chain stores have
able.52,53 In Pakistan, the use of public facilities is even lower in qualified pharmacists at the front desk; the majority of phar-
rural areas compared with urban areas.54 Reasons could macies are run by non-qualified lay persons who obtained
include restricted hours of operation, distant location from the their knowledge about drugs from experience of running their
population and a dearth of qualified female health providers.16 own business or working in some other retail pharmacy
Lack of health education, non-availability of drugs and low prior to starting their own business. Hussain et al. reported
literacy rates in rural areas may also be contributing factors.55 that 32% of the population surveyed claimed that they
It has been noted that most healthcare in Pakistan is acquired medicine from pharmacies or chemist shops without
provided at general practitioners’ clinics.56 Current reviews of prescription.26
available literature found a similar trend, with 70% of the Self-medication was found to be a common practice in the
population surveyed by Manzoor et al., 57% in the study by literature reviewed. About 45%,67 26.2%,68 63%,69 25.5%,41
Mahmood and Ali, and 68% in the study by Hasan and Kha- 13%70 and 11%23 of the participants surveyed reported using
num using or preferring to use the private sector in their quest homemade and commercially prepared remedies for the
of health seeking.35,57,58 Mull and Mull reported that the treatment of their ailments. Self-treatment has also been
majority of mothers would only take their children to found to be a common initial response to illness in other
government facilities if the private practitioners failed to treat studies reviewed.71e73 In one of the studies, the reasons cited
pneumonia successfully.34 In contrast, Fatmi and Avan by people for practising self-medication were a good previous
reported that of all the women (29.3%) who used antenatal response to medicines, saving time and money, and inacces-
care during their last pregnancy, 72.3% preferred the govern- sibility of doctors.69 Certain other studies have reported self-
ment healthcare provider.59 This could be attributed to the medication as a common practice but did not investigate the
location of the facility in close proximity to the residential reasons for this, making it an important and interesting aspect
area. The review found that the most commonly cited reason for future study.
for not using the government healthcare facility in rural areas Self-medication in industrialized countries is less of
was ‘inability to reach the health facility due to distance’ a necessity and is mainly guided by relatively responsible
which may be further aggravated by poor transport information gained from books, magazines, package inserts
services.35,58 Other reasons cited, which are also consistent and other media, and dangerous drugs are kept from unpro-
with the findings from other developing countries, are fessional use. In developing countries, however, it is more of
absence of doctor and paramedic staff, shortage of medicines a necessity due to poverty and inaccessibility to the formal
and poor quality of care, which keep people away from using healthcare setting.62 Consumers from developing countries
514 p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) 5 0 7 e5 1 7

mainly rely on advice from family and friends, over- Throughout the life cycle, gender discrimination in child rear-
prescribing physicians and the marketing campaigns of the ing, nutrition, healthcare seeking, education and general care
pharmaceutical companies.74,75 make women highly vulnerable and disadvantaged.82 From the
beginning of life, female children are given lower priority than
Involvement of traditional and informal healers in the male children.83 Hasan and Khanum found that boys were
healthcare system twice as likely as girls to be taken to healthcare providers,
apparently showing gender discrimination starting from
Use of complementary and traditional medicine has not only childhood itself.58 While this could be partly due to girls being
become widespread in developing countries during the last better off biologically and coping better than boys in unfav-
decade but has also expanded to developed countries.76 ourable circumstances, differential healthcare practices may
According to World Health Organization (WHO) reports, two- make girls vulnerable later.84 Qureshi et al. cited not having
thirds and 50e80% of the population of developed and devel- authoritative powers in the household and lack of education as
oping countries, respectively, used traditional medicine.77 possible reasons for women’s delay in health seeking.85 The
Traditional medicine has been defined by WHO as: ‘a sum importance of improving the educational level of women was
total of the knowledge, skills and practices based on the also highlighted by Zahid, who linked it with child mortality
theories, beliefs and experiences indigenous to different rates.86 The findings of Bhatti et al. and Bhatti and Fikree,
cultures, whether explicable or not, used in the maintenance whereby men are held least responsible for conditions such as
of health as well as prevention, diagnosis, improvement or infertility and reproductive tract infections in women, are also
treatment of physical and mental illness.’77 In developing consistent with the overall scenario of the low social status of
countries such as Pakistan, the informal healthcare sector not women.42,72 However, this is not always the case, as Ali et al.
only includes traditional healers (Hakeems in local language), and Ladha et al. found that gender had no significant effect on
but also homoeopaths, spiritual and faith healers, boneset- health-seeking behaviour.38,43 The possible reasons could be: (i)
ters, traditional birth attendants (Dais in local language) and the studies were conducted in cities; and (ii) one study focused
quacks. This sector accounts for more than 70% of consulta- on elderly people and elderly women might not experience the
tions in the country.78 In this medical pluralism where formal same discrimination as younger women.38 However, such
and informal sectors operate hand-in-hand, ‘healer shopping’ findings show the need for more in-depth research on gender
can be a common practice. As is evident from some of the disparity, not only in rural areas but also in urban communities
literature reviewed, people tend to change healers more and in different age groups.
quickly as they want quick results.68,79 Switching healer may
work two ways, which is switching from informal (traditional) Superstitions, myths and misconceptions
healthcare services to formal healthcare services or vice versa.
However, little is known about such behaviour in Pakistan Myths and fallacies have long played a role in making and
except for the work of Hunte and Sultana which investigates shaping societies and their cultures in terms of social behav-
the pattern of utilization of formal and informal healthcare iours, cultural values, disease conception and health
services.68 The literature reviewed shows clear evidence of seeking.34 As culture and traditions are inherent, certain
involvement of the informal sector at some level in people’s rituals and practices carried out ancestrally in the field of
journey to health seeking.36,42,45,57,68,70e72,80,81 Some of the health or social behaviours become a part of modern culture
reasons for using or preferring informal services documented as well.87 The beliefs vary from region to region, are quite
in the literature reviewed are poor socio-economic status, distinct in different ethnic settings, and are known to influ-
strong beliefs, lower cost and easier access. Improved educa- ence health and disease states in a variety of ways.88 There are
tion levels have been found to challenge some traditional many superstitions in the world based on religion, old stories,
beliefs and positively affect the use of modern health services; legends, fortune telling and personal experience.89 In devel-
however, not many studies have focused on those educated oping countries, social myths include food fallacies, tradi-
people who believe in and use informal services. tional practices for disease cure, quack referral and
misinterpretation of religion.90e92 This literature review only
Women’s autonomy and gender discrimination found one study that focused specifically on investigating
superstitions regarding health problems in Pakistan.45 This is
Discrimination against women, especially in developing discussed under the heading of emerging themes because of
countries, is a devastating reality. In an Islamic country such as its strong and undeniable relevance overall in health seeking
Pakistan, where religion plays an important role in everyday in Pakistan. Qureshi and Shaikh discussed the common
living and gender-specific roles are clearly defined, one can myths, fallacies and misconceptions pertaining to health-
expect different health-seeking behaviours in men and seeking in Pakistan in detail, and suggested the use of social
women. However, certain social and cultural beliefs and reli- marketing for promoting appropriate health-seeking behav-
gious misinterpretations at times have earned a lower social iour in Pakistan.87 Some other studies also highlighted the
status for women, especially in rural areas. More than two- presence of strange beliefs in society, such as beliefs per-
thirds of Pakistan’s population, of which approximately 50% taining to supernatural aetiologies of illness,68 sunken fonta-
are women, live in rural and remote areas of the country with nelle as the cause of diarrhoea, considering diarrhoea to be
minimal access to quality health services.24 The dearth of a natural condition,81 applying onion to snake bites,41 and
female health service providers in rural areas has further believing that coldness is the cause of phlegm.79 Although
hindered women’s use of appropriate and timely medical care. superstitions and myths have traditionally been associated
 p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) 5 0 7 e5 1 7 515

with rural communities and people with low socio-economic healing’. Nevertheless, there is a need to increase awareness
status and educational level, little is known about the pres- among the public to prevent them from replacing conventional
ence of such beliefs in urban areas and people who are well treatment with spiritual healing.
educated and financially well-off. Serious efforts are required to increase the awareness and
education level of women, especially in rural areas of Pakistan.
There is a strong need to interpret the religious teachings
Conclusions correctly in order to bring respect and social liberty into
women’s lives and to offer them their actual social status.
To conclude, health-seeking behaviour in general, and Similarly important is the need for identification of different
specifically in the context of developing countries such as superstitions and misconceptions regarding health problems
Pakistan, is strongly affected by sociocultural and religious prevailing in the Pakistani population.45 Any intervention
influences. In order for health policies to be more effective and design ought to address such misconceptions and societal
acceptable, there is a strong need to understand the drivers of barriers towards appropriate and just utilization of health
health-seeking behaviours by expanding the research into services.96 Education is key to attenuate the intensity of such
those geographical areas, age groups and medical conditions fallacies and misconceptions which hinder the people from
that have been neglected. The review has found that health- seeking appropriate healthcare.
seeking behaviour has mainly been viewed through a retro-
spective window. A prospective approach is required in order
to understand the habits and practices of people from this part Acknowledgements
of the world. Clinic-based studies present useful data, but
people attending a particular health facility are usually Ethical approval
different from those who do not attend.79 To capture those
None sought.
who do not visit any formal healthcare facilities, more
community-based research and research approaching the Funding
people in informal settings is imperative.
Important themes found to be consistent in the literature None declared.
included preference for the private sector over the public sector,
Competing interests
self-medication, involvement of traditional and informal
healers, gender discrimination and certain superstitions,
None declared.
myths and misconceptions associated with health-seeking
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