Abstract

Dengue fever casts a looming shadow over Rawalpindi, Pakistan, as its seasonal outbreaks unleash a formidable onslaught on local healthcare resources, painting a challenging portrait of public health in the region. This ethnographic investigation delves into the health-seeking conduct of dengue sufferers in a healthcare milieu marked by an assortment of treatment approaches. Employing qualitative methodologies comprising in-depth interviews, participant observation, and focus group deliberations, this inquiry provides invaluable discernment. socioeconomic circumstances, and symptom gravity that steer patients towards traditional, alternative, allopathic, or amalgamated remedies. Significantly, our findings elucidate that patients initially opt for folk or popular-sector therapies due to their ease of access and cultural influence. As their symptoms exacerbate, they transition to the professional sector, seeking allopathic care. The results of this study underscore the pivotal role played by factors such as knowledge gaps, financial limitations, constrained comprehension, and systemic healthcare impediments in shaping patients' preferences.

Key Words

Dengue Fever, Vector-Borne Diseases, Health-Seeking Behavior, Medical Pluralisms, Rawalpindi

Introduction

Dengue fever, a mosquito-borne viral disease caused by the dengue virus and transmitted primarily by Aedes mosquitoes, has emerged as a significant public health concern in many parts of the world, including Pakistan. More than 40% of the world's population, or over 2.5 billion people, currently resides in dengue-endemic areas. Pakistan had 25, 932 confirmed dengue cases and 62 deaths (CFR 0.25%) between January 1 and September 27, 2022, with 74% of these cases in September (Khan & Khan, 2015). Cases have increased after catastrophic flooding in mid-June 2022. Since the flood crisis is hurting the national health system and the humanitarian situation is growing, dengue fever and other illness epidemics pose a severe health concern (Waqar, 2016). Dengue fever epidemics in Rawalpindi, Punjab, have caused health and economic problems for locals. Dengue patients mostly came from Satellite Town, Shamsabad, Raja Bazaar, Afzal Town, Bakra Mandi, Dhoke Munshee, Chaklala, and Kotha Kalan (Tabassum, 2023). These outbreaks have caused great morbidity and mortality and burdened the healthcare system and local resources.

Understanding dengue patients' health-seeking behavior (HSB) is vital in the midst of ongoing dengue epidemics in Rawalpindi because there are no antiviral drugs available for dengue and only supportive care is accessible. People who feel sick or at risk engage in health-seeking behavior. Dengue outcomes can be affected by timely and proper healthcare-seeking. Early diagnosis and treatment can prevent dengue from worsening and limit community transmission (Shahid, 2022). The complex interaction of cultural attitudes, socioeconomic variables, and individual perspectives can affect whether and when people seek dengue treatment. These characteristics must be understood to design successful public health interventions and strategies to improve healthcare-seeking behavior, reduce dengue burden, and improve community well-being. 

Multiple healthcare systems coexist without disruption in Rawalpindi, a pluralistic paradigm. In addition to alternative and allopathic medicine, local healers employ centuries-old cultural practices. (Winch, 2002). This diversity helps Rawalpindi residents navigate the city's complex healthcare system. Dengue patients must choose between many healthcare systems, making fascinating trade-offs. This study will reveal Rawalpindi residents' dengue fever risk-management decisions and determinants. This ethnographic study examines Rawalpindi dengue patients' health-seeking behaviors in a pluralistic healthcare environment. The study examines the complicated beliefs, economic constraints, and contextual factors that lead dengue patients to choose traditional, alternative, allopathic, or mixed therapy. This research seeks to understand how Rawalpindi's different healthcare demands are met by these multiple healthcare systems through dengue patients' unique narratives and experiences. This study aims to advise healthcare policymakers, practitioners, and researchers on how to improve healthcare coordination and delivery in this pluralistic approach, improving public health in Rawalpindi and beyond. 

Literature Review

This research is situated within the domain of medical anthropology. Dengue fever is a major global health concern, and numerous studies have explored the health-seeking behavior of individuals affected by this mosquito-borne disease. Research in this area has yielded valuable insights into the factors that influence when and where individuals seek healthcare for dengue symptoms. Most studies have been conducted on dengue, which occurs in many countries around the world, including the Americas, Africa, the Middle East, Asia, and the Pacific Islands (Brathwaite Dick et al., 2012). Although dengue fever poses a serious public health threat in Rawalpindi, the majority of the studies currently in circulation focus on epidemiological issues, clinical management, and vector control techniques (Rizwana Hussain, 2019). However, a thorough understanding of how people interpret, respond to, and perceive a dengue symptom in their social and cultural contexts is inadequate. Any actions performed by people who believe they have a health issue or are ill to find a suitable treatment are referred to as health-seeking or care-seeking behavior. (Webair, 2013). Thus, research on dengue fever health beliefs and practices, HSB, and access to care is needed to identify difficulties and opportunities for adopting these cutting-edge diagnoses and treatment advances. Dengue HSB knowledge can improve late diagnosis, treatment adherence, and culturally appropriate health promotion (Müller et al., 2003).

Different ethnographic studies reveal that many people sought therapy from traditional healers or tried to treat themselves due to incorrect perceptions about the illness. Venezuelan dengue patients often wait more than three days to visit a doctor (Brasier et al., 2012). He was already critically ill. Because delays in seeking care have been linked to severe dengue complications, emphasizing the need to understand HSB and provide dengue patients with care (Khun & Manderson, 2007).  Patients' treatment-seeking behavior is influenced by their belief that their fever is moderate rather than dengue fever and poor healthcare facilities that lack early detection. Also important is the impact of demographic and socioeconomic factors on dengue patients' treatment behavior. In Pakistan, where men make all healthcare decisions for their families, prejudice based on gender plays a role in delaying women's access to care. (Shaikh, 2004). In the context of dengue fever (DF) the health-seeking behavior of individuals is primarily influenced by their knowledge and attitude when selecting methods and basic healthcare facilities.

Goldman and Heuveline (2000) conducted a study on health-seeking behavior in Guatemala, which revealed that individuals in this population often decide to consult a pharmacist rather than a medical doctor when seeking treatment. Moreover, a significant majority of individuals prefer private practices as their initial choice for seeking medical treatment. This study uncovers similar findings in both India and Pakistan, highlighting the existence of two distinct categories of health practices: favorable and less favorable. These practices are observed among patients and healthcare practitioners. (Shaikh, 2004). In the context of dengue fever (DF), the health-seeking behavior of individuals is primarily influenced by their knowledge and attitude when selecting methods and basic healthcare facilities.

Healthcare activities like disease diagnosis and treatment are related in every community. The healthcare system helps society's beliefs, conventions, positions, power connections, and methods of interacting make sense, hence it's necessary to discuss it. Kleinman (1980, p. 24) calls a society's healthcare system a cultural system. This cultural system has symbolic meanings anchored in social institutions and interpersonal relationships. Healthcare systems combine attitudes about illness, healing practices, treatment ideas, clinical surroundings, establishments, roles, and hierarchies. Medical systems are innovative amalgamations of indigenous ideological and practical components, sometimes modified from exterior cultures, according to Gaines (1991, p. 243). Healthcare systems are affected by cultural, political, economic, historical, and environmental factors.

According to Kleinman, (1980, pp.49–60) the healthcare system is the local cultural system with intersecting popular, professional, and folk sectors. In the popular sector, family, neighborhood, and community members consult to heal or care for ailing family members. If they select modern, organized scientific medicine, they become healthcare professionals. Doctors, nurses, and other healthcare workers drive this discussion. Folk medicine, herbalism, and homeopathy comprise the third sector. Kleinman (2017) states that areas have distinctive explanations, social positions, interactions, and institutions. Most healthcare and health maintenance are public. 

Culture affects how people view illness and their health. Geertz argues this cultural system maps a given area of human behavior (Kleinman, patients, and therapists in the context of culture: An examination of the borderland between anthropology, medicine, and psychiatry, 1980, p. 26). According to Geertz (1973), cultural norms and beliefs provide a context for health-related behaviors. WHO describes traditional medicine as health practices, methodologies, knowledge, and concepts that address health issues with herbal, animal, and mineral-based minerals, spiritual therapies, and manual, and exercise techniques. Any medical method not influenced by Western science is included. Non-Western medicine is criticized for being founded on superstition and ignorance, and its paradigm is rarely explained. Traditional healing and environmental issues are gaining popularity worldwide. This is seen in complementary and alternative medicine. Traditional healing methods are cheaper, easier to get, and accepted in low- and middle-income nations where there may be fewer professional doctors. Carica papaya and Euphorbia hirta are the most commonly used plants for treating DENV infections across various geographical areas, according to previous studies that documented the traditional use of 25 plants for dengue treatment (Sarala, 2014). Westerners criticize CAM treatments because they don't fit Western medical ideas. Indigenous healers focus on emotional and cultural aspects of acute or non-life-threatening disorders, according to Kleinman (1980, p. 361).

Help-seeking behaviors vary based on symptoms, patient and family beliefs and past experiences with illness and treatment (Kleinman, 1980), perceived impact on personal relationships, work obligations, or physical abilities, healthcare accessibility (Zola, 1973), social class, and gender. Helman (1990) states that social, cultural, and emotional factors influence medical treatment decisions rather than illness severity.

Methodology

In the pursuit of comprehending the health-seeking behavior of dengue patients in Rawalpindi's pluralistic healthcare system, a purposive sampling strategy was meticulously employed, ensuring representation across various demographics like age, gender, socioeconomic status, and geographical location within the city. Employing qualitative research methodologies such as key informant interviews, focus group discussions, in-depth interviews, and participant observations, this study delves into the unique contours of dengue's social construction within the local context. A diverse cohort of 25 dengue patients and 15 caregivers, supplemented by a patient-focused focus group, were engaged in the research. Thematic coding emerged as the analytical tool of choice, meticulously organizing and unraveling the intricate tapestry of health-seeking behaviors amid a multifaceted healthcare landscape. 

Throughout this investigation, it becomes clear that dengue in this region has a distinct personality, influenced by cultural norms, economic realities, and community-wide actions. Its perception can vacillate between stigmatization and normalization, intricately interwoven with notions of hygiene and lifestyle. Crucially, the role of collective efforts driven by community leaders and government campaigns looms large in dengue prevention, while economic disparities cast a formidable shadow on healthcare accessibility, influencing how individuals grapple with the financial implications of dengue. In this narrative, the media's portrayal and the dissemination of information through social networks play pivotal roles, exerting significant influence on public comprehension. In summation, this study endeavors to uncover the nuanced and multifaceted experiences of dengue patients within their cultural and socioeconomic milieu, shedding light on the intricate interplay of factors that shape their health-seeking behaviors.

Result and Discussion

The anthropological research sheds light on the complex patterns of care-seeking behavior among dengue patients in Pakistan. The research provides insight into the decision to seek medical attention for dengue symptoms. It highlights the fact that the severity and diversity of dengue illnesses necessitate a wide range of treatment approaches. In Pakistani culture, people seek treatment based on their perceived illness susceptibility and symptom severity. Accepting the sickness and acknowledging its severity is essential to obtaining treatment. Some responders initially deny having dengue, underestimating its severity due to a lack of awareness or imagined resistance. Disease acceptance is also affected by the prospect of a difficult and painful treatment process, perhaps riskier than the sickness. Dengue symptoms include "bone-breaking pain" and "snake fever". Another sufferer characterizes dengue as "mourning" after a death. Interestingly, mothers, in particular, may downplay initial fever symptoms in children, delaying their recognition of dengue symptoms.

"According to a mother, at the beginning, she had a mild fever. I did not know what it was, and I did not know it was a DF. I purchased paracetamol (paracetamol) for her, but when I touched her, I saw that she was cold. The next day, her condition worsened, and she fainted"

Additionally, there is a prevalent belief that the severity of dengue is linked to an individual's immune system. This belief leads some, especially healthy teenagers, to perceive themselves as less susceptible to dengue.




Kleinman’s System of Health Care and Patterns of Treatment-Seeking Behavior

The study's findings demonstrate that the first line of treatment for dengue typically involves the use of non-prescription pharmaceuticals and complementary and alternative medicine (CAM). Most participants reveal that people often begin with folk or popular sector treatments, influenced by cultural beliefs and the accessibility of remedies. However, as symptoms worsen or in severe cases, individuals typically turn to the professional sector for allopathic care. Kleinman’s model highlights the dynamic interplay between these sectors in healthcare decision-making (Kleinman, 1980).

The folk sector, encompassing traditional healers and indigenous practices, serves a unique purpose in addressing non-life-threatening diseases like dengue. Local remedies using fruits, spices, and herbal treatments are often utilized, particularly during the early stages of the disease. A patients shared,

"Fenugreek seeds can be soaked in a cup of boiling water with a few drops of lemon and boiled. Drink the water twice a day after letting it cool. Fenugreek water will lower your fever and strengthen your immune system"

Trust in traditional healing practices and cultural identity play significant roles in treatment choices. Faith healers also feature prominently, introducing religious elements into patients' lives through Quranic verses and taweez (amulets), emphasizing the cultural and spiritual dimensions of healthcare. A caregiver said that her mother, who is a patient, regularly takes the medicine prescribed by the doctor but also strictly follows the Wazifa.  Practice reciting verses or phrases to seek a specific favor or reward that a local faith healer suggested to her.

Both Damm's Spiritual healing techniques and dawa Medicine (medicine) have their purpose.

A patient's mother said,

"The neighbors told me about a few places from where good oil could be found. Tried and tested things should be used at least once"

Within the popular sector, individuals turn to over-the-counter medications, widely recognized remedies, and easily accessible information sources. This sector reflects the role of public knowledge and Internet resources in influencing healthcare decisions.

"A patient shared that, "There are a lot of drugstores anywhere, from the city to the countryside. We can buy most of the drugs that we need at any time. The prices of store drugs are much cheaper than hospital drugs"

Some interviewees sought information about dengue treatments online, reflecting the role of accessible information sources in the popular sector. They felt informed and chose to try herbal remedies based on their research, demonstrating how public knowledge and internet resources can influence healthcare decisions.

"I read about various treatments for dengue online, and that's how I learned about herbal remedies. I felt informed and decided to try them."

The professional sector, comprising doctors, nurses, hospitals, and clinics, plays a critical role in severe dengue cases. Individuals seek allopathic treatment in this sector when symptoms escalate, highlighting its importance in managing the disease's severity. Some healthcare providers even consider complementary therapies alongside allopathic treatment, illustrating the integration of multiple healthcare approaches within this sector. Previous study findings show that when treating suspected dengue infections at home, it is crucial to follow up with a doctor's visit for thorough medical monitoring (Basra, 2019).

"I initially tried some home remedies for my dengue symptoms, but when they worsened, I decided to consult a doctor. The doctor prescribed allopathic medications, which significantly improved my condition."

Another patient said, "I don't believe in all of these I only believe in things that have scientific support. However, I suppose that when you are in a desperate situation, you just want to try anything to get better because, after all, there is no treatment for dengue"

The research findings provide valuable insights into the complex healthcare-seeking behavior of individuals affected by dengue disease in Pakistan. It highlights the intricate interplay between cultural beliefs, symptom severity, information sources, and the flexibility of healthcare providers in shaping treatment decisions.  A patient who was from a village setting where she used to work in the fields commented that she was feeling not much better; she said that had killed her. She showed her arms, saying she could not move them. 

"Nothing much can be done. If admitted to the hospital, they will only be put on drips to provide them with fluids; they don’t want to get dehydrated. Since my weakness and fever are still present, these medications are not a cure. They only reduce the severity of the disease and provide relief"

Although, in written documentation during the treatment and diagnosis process, the professionals adhered to the scientific knowledge of the disease, they tended to disseminate individualized conceptualizations of the disease when counseling the patient. Here, the lines between the professional and popular sectors blur. Doctors are professionals, so they are part of the professional sector, but they are also people who live in a society and have their ideas about the disease that they may or may not show in the hospital. 

There is a difference in socio-economics between people in the professional and folk sectors of health, which may also be a factor in who goes to which sector of health. In our study, most of the people who took part had contacted the folk health sector at different points in their treatment. Some people first went to their faith healers and then went to a doctor, while others used both types of health care at the same time because they thought that Dam and Dawa were complementary for health problems. Due to the value of all parts of health, we need to create an integrated healthcare system that includes both scientific/biomedicine and complementary and alternative medicine (CAM).




Factors Influencing Health-Seeking Behaviour: In the realm of healthcare, especially in the context of managing dengue fever, a complex web of challenges and deficiencies weaves together to influence patients' experiences, decision-making, and overall well-being. This intricate tapestry is marked by several distinct factors, each with its own set of intricacies and intricacies that impact the trajectory of dengue patients and their families. Delving into these multifaceted dimensions, we uncover profound insights into the struggles faced by individuals grappling with this mosquito-borne illness.

Gaps in Information Provision and Patients' Knowledge: One prominent facet of this narrative revolves around the gaps in information provision and patients' knowledge. Patients often find themselves inadequately informed about the various stages of dengue and its warning symptoms. Their understanding is often limited to common indicators like vomiting, bleeding, and diarrhea, leaving them unaware of the broader spectrum of potential signs. Such limited knowledge can delay timely medical intervention, as patients may not recognize the severity of their condition until it reaches a critical stage.

"I continued to vomit every five minutes....... I simply take a break and keep drinking a lot of water. However, I still vomited water even after drinking it. Since I went to the clinic at an earlier time and the doctor indicated that I have the beginning stage of dengue fever, I will just have to wait until the next day. So, I visited the hospital"

Many responders may have assumed that the fever was just another common fever, as was the case in the earlier study, and this may have contributed to the delay (Kamat, 2006). 

Social Factors and Symptom Severity: Another layer of complexity stems from social factors and symptom severity, which heavily influence patients' health-seeking behavior. The severity of symptoms often dictates whether patients seek medical attention, with some patients delaying hospital visits due to caregiving responsibilities or lack of available support. This social dimension highlights the critical role that family and social networks play in the decision-making process, sometimes at the expense of patients' health.

"When I was diagnosed with dengue, my family from my hometown …. came to my house; they took my two children back to my hometown. So, I was not looking after my children at that time, and I was with my sister only. My sister can take care of me and send me to the hospital in an emergency"

Economic Challenges and Accessibility Issues: Economic hardships form yet another thread in this complex tapestry. Dengue and other illnesses can drain families' finances, pushing them into financial instability. The cost of treatments and medications, coupled with the loss of income due to illness, exacerbates the economic burden. Patients are often left dependent on their families, leading to a sense of helplessness and frustration.

A patient said,

"I was making money before I was diagnosed with this illness. I was employed as a driver. But the moment I was diagnosed with this illness, I was lost. I grew completely dependent, and I've had a miserable life. A significant issue in this place is finding food. I have to wait for the kids to provide... My primary duty has been to sit at home. I have no power. There is a serious issue here"

Access to healthcare services, particularly in remote areas, is a significant challenge. Limited access to medications and healthcare facilities due to geographical barriers, high transportation costs, and seasonal difficulties further compound patients' struggles. This study confirmed prior research findings indicating that the cost of treatment influences patient behavior (Khun & Manderson, 2007). Patients in remote regions are forced to travel great distances, often enduring harsh conditions, just to access essential medical care. 

According to another participant, "I need to have enough money for return transport, accommodation, and food before I can think about going to the clinic, and that doesn't include the money for laboratory tests and medicines... I do not have much money. I just leave everything to God. If I have money, I go get the medications; if not, I stay at home and do not take them"




Lack of Understanding and Empowerment

A lack of understanding, both in terms of medical terminologies and the decision-making process, adds layers of difficulty. Patients express a desire for clearer explanations and more active involvement in their healthcare decisions. Empowerment through education and participation in the decision-making process is crucial for patients to navigate their healthcare journey effectively.

"We are illiterate patients. When marking our medications, they must include information about how often to take them and whether to take them before or after meals. When it happens, it will be advantageous for us"

One of the patients said,

If we were literate, we could better understand our diseases and then participate in decision-making. Patient empowerment is important because it helps patients deal with the psychological aspects of their disease. The more informed the patient is, the more they can identify the best possible options for their care.




Issues Related to Health Services

In Pakistan, patients grappling with diseases like dengue and malaria face daunting challenges within the healthcare system. Overcrowded public hospitals often leave healthcare providers with little time for individual patients, resulting in feelings of neglect and unheard concerns. The strain of dengue peak periods exacerbates resource shortages, affecting the availability of beds, medical equipment, and staff, potentially compromising care quality. Disturbing experiences within dengue wards, marked by long waits and witnessing fellow patients in distress, add to the ordeal. Sleeping pills are often necessary to counteract the noise in cramped conditions. 

A patient said,

"I should have been admitted to the hospital, but they were full of dengue patients and had no bed for me. I was unable to stand due to my weakness. I am hardly ever sick, but I thought I was going to die"

Frustration with government doctors' perceived neglect drives some patients to seek medication from external sources. Limited access to specialized services and infrequent visits from senior doctors compound patients' anxieties. While patients value the doctor-patient relationship, they express dissatisfaction with the limited time doctors can allocate, particularly in government healthcare facilities. Overall, there's a strong desire for more information and understanding about their conditions. A Patient account highlights the struggle for attention in chaotic hospital settings, echoing the sentiment that it's hard to receive care. Additionally, it hinders their ability to contribute to the effective implementation of healthcare policies, programs, and innovation (Khan & Van den Heuvel, 2007). The mistrust of the healthcare system results in a power imbalance.

Conclusion

This anthropological study delved into the health-seeking behavior of patients and caregivers grappling with diseases like dengue in Pakistan, where these illnesses pose a substantial burden on the healthcare system, exacerbated by factors like severe flooding. The research can help us understand the diverse experiences and perceptions of dengue fever, and how cultural paradigms, social norms, and personal meanings shape the social context of the condition.  It also sheds light on the diverse medical systems coexisting in society, from professional healthcare to folk and traditional remedies. Cultural beliefs overlap and have an impact on these systems, highlighting the significance of developing healthcare strategies that respect patient preferences and have faith in a variety of medical options. While universal health coverage can address financial barriers, understanding plural medical systems provides a more nuanced approach to healthcare utilization and dengue management. The results of this study suggest that dengue hemorrhagic fever patients' health-seeking behavior is not adequate, which delays treatment, and the resulting possible alternatives to hospitalization for the patient are time-consuming. The findings emphasize the urgent need for comprehensive healthcare reforms in Pakistan to address these challenges and improve the healthcare experience for dengue patients and beyond.

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