What resources do elderly people choose for managing their symptoms? Clarification of rural older people’s choices of help-seeking behaviors in Japan

What resources do elderly people choose for managing their symptoms? 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Clarification of rural older people’s choices of help-seeking behaviors in Japan Ryuichi Ohta, Mikiya Sato, Yoshinori Ryu, Jun Kitayuguchi, Tetsuhiro Maeno, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-124413/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Appropriate help-seeking behavior (HSB) that involves lay and professional care may moderate the usage of medical resources and promote good health, especially among the rural elderly. However, there is little evidence regarding the rural elderly’s HSB choices for mild symptoms. Therefore, this study attempts to bridge this gap. Methods The participants were patients living in rural areas and over the age of 65, who attended Japanese clinics and general hospitals. In Phase 1, monthly diaries and one-on-one interviews about their mild symptoms and HSB were used to establish checklist items and assess content validity. Content analysis helped determine the items. In Phase 2, participants were asked to complete the checklist to measure HSB. The checklist answers and HSB mentioned in the diaries were compared to evaluate construct validity. Retests were conducted to examine the content’s reliability and test-retest reliability. Results Phase 1 included 267 participants (average age = 75.1 years, standard deviation [SD] = 4.3; 50.1% male). The diary collection rate was 97.6%. Of the participants, 70.4% used lay care and 25.4% used professional care. Content analysis identified eight types of lay care and four types of professional care. Phase 2 included 315 participants (average age = 77.7 years, SD = 8.27; 46.0% male). In terms of validity, the results of the checklists and the diaries were correlated (Spearman p 0.704; p < 0.001). The most common behavior with mild symptoms was consulting with primary care physicians, followed by self-care and using home medicine. The test-retest reliability for mild symptoms found kappa values of 0.836 for lay care and 0.808 for professional care. Conclusions The list of rural older people’s choices of HSB for mild symptoms had high validity and reliability. Therefore, it can be used to assess the relationships between HSB and health conditions and the effectiveness of health promotion on HSB among rural elderly people. Health Economics & Outcomes Research Health Policy elderly patients help-seeking behavior Japan lay care professional care Introduction Help-seeking behavior (HSB) is a human behavior that sustains health and involves seeking treatment for symptoms. It is an essential behavior for maintaining peoples’ health, and ideally each person should have appropriate HSB. This requires people to assess their symptom and its severity, use lay care to manage these symptoms, followed by professional care as needed [ 1 ]. Suitable HSB can connect people with appropriate care and enhance peoples’ health in ways such as better quality of life [ 2 ]. A balance of lay care and professional care is important for appropriate HSB [ 3 ]. Lay care is care provided by lay people, or those who have received no formal training and are not paid, such as self-care and care from relatives, friends, and self-help groups, while professional care refers to care provided by trained paid professionals, usually in a formal setting [ 4 ].The efficient usage of lay and professional care can reduce people’s inappropriate HSB [ 5 , 6 ]. HSB varies relative to healthcare resources. In urban areas, there are many medical resources, allowing for choice between various medical and healthcare professionals [ 1 ]. However, citizens in rural areas lack adequate resources for medical care, leading to inappropriate HSB such as usage of medical care for mild symptoms [ 7 ]. Limited education among people living in rural areas may also affect HSB [ 8 – 10 ]. In addition, rural HSB needs to be improved by providing information and educational interventions of HSB from multiple perspectives as these people may also lack information about medical issues [ 7 , 11 ]. Although the Internet and social media have advanced, they are primarily used by young and middle-aged people. The elderly tend to obtain information from television and newspapers [ 12 , 13 ]. A lack of information may lead to inappropriate HSB especially for mild symptoms [ 14 ]. Furthermore, it results in excessive usage of medical resources and undesirable results for citizens’ health [ 2 ]. Rural older people’s HSB for mild symptoms can be improved by continuously providing them with accurate information about their symptoms and healthcare [ 15 ]. Therefore, it is crucial to assess their HSB for mild symptoms to suggest modifications. Thus, comprehensive checklist of rural older people’s HSB choices, that is reliable and valid evaluating the rural older people’s HSB for mild symptoms should be constructed [ 16 ]. Also, HSB for mild symptoms can be assessed in terms of the relationship with their demographic. Currently, no research has clarified comprehensive checklist of rural older people’s HSB choices, that is reliable and valid, regarding rural older people’s HSB for mild symptoms. Therefore, this study aimed to create comprehensive choices that can accurately assess rural older people’s HSB for mild symptoms. Methods Setting Unnan City, located in southeast Shimane Prefecture, Japan, is primarily covered by forest and is one of the most rural cities in Japan. A 2017 survey revealed the total population was 38,882 (consisting of 18,720 males and 20,162 females) and that the percentage of people over the age of 65 was 37.82%; this is estimated to reach 50% by 2025. Kakeya and Tai Clinic are rural clinics in Kakeya and Yoshida Town, the towns situated in the most northern part of Unnan City. Both clinics are about 30 km from Unnan City Hospital, the only general hospital in the city. Kakeya Clinic has five registered physicians, two nurses, and no admission facilities. Tai Clinic has three registered physicians, two nurses, and no admission facilities. All the physicians in both clinics are family medicine specialists. At the time of this study, Unnan City Hospital had 281 beds comprising 160 acute care beds, 43 comprehensive care beds, 30 rehabilitation beds, and 48 chronic care beds. There were 14 medical specialties, and the nurse-to‐patient ratio was 1:10 in acute care, 1:13 in comprehensive care, 1:15 in rehabilitation, and 1:25 in chronic care. Participants The participants in this study were patients over 65 years who attended Kakeya and Tai Clinic and Unnan City Hospital for regular health checkups. All participants lived in Unnan City. They were informed about this study via advertisements, and an explanation of the purpose of the research was included in the list and monthly health diary. Patients who could not read, write, or hear properly and patients with dementia were excluded from this study. Phase 1: Instrument development Monthly health-check diary The diaries consisted of a space for noting the date, patient’s blood pressure, existence of symptoms, kinds of symptoms, and how they managed the symptoms (i.e., HSB). The participants checked whether they had symptoms at the end of each day for one month. The clinic nurses collected the diary pages when the participants visited the clinic one month later. If there were unclear terms in their diary, the clinic nurses checked their symptoms and their approach to the symptoms in depth and wrote this on the diary page in red ink. One-on-one interviews and a review of previous studies to confirm the content validity : To create a valid HSB list, participants’ HSB was first transcribed based on the diaries. Next, purposive sampling was used to choose 39 participants (20 from the clinics and 19 from the hospital) to be interviewed about their potential HSB for mild symptoms to confirm content validity, in line with previous studies [ 16 , 17 ]. The Interview guides consisted of four questions based on the previous HSB research: “What kind of symptoms do you have in your usual lives?” “How do you act when you have mild bodily symptoms?” “Why do you act so?” and “Please describe your concrete experiences[ 18 ].” To define mild symptoms, previous research was referred to regarding HSB. Based on these findings, participants were shown examples of mild symptoms: mild fatigue, flu-like symptoms, joint pain, back pain, and mild headache [ 16 ]. The contents of the interviews were then recorded and transcribed verbatim so the first and second authors could review the interview and diary transcriptions based on the content analysis method [ 19 ]. Through this process, the list of options of potential HSB was finally constructed. Phase 2: Testing the validity and reliability of the HSB list The participants were given the constructed list of options of their potential HSB. Multiple answers were allowed for each question. By comparing the answers on the list and the results for the HSB in the monthly diaries, the validity of the list was assessed. Lists were completed in the waiting room at the clinic and then collected by nurses. To confirm the reliability of the HSB list, all participants were provided with the constructed HSB list twice, ensuring test-retest reliability. The interval between the two rounds of list completion was one month. The participants’ data were also extracted from the clinic’s electronic medical record and a questionnaire including age, sex, work conditions, exercise habits, eating habits, sleeping habits, smoking, habitual alcohol drinking, educational level, living conditions, social support [ 16 ], social capital (using a 10-point Likert scale: can rely on neighbors in communities to completely not rely on neighbors in communities) [ 20 ], socio-economic state and health literacy (HLS-14) [ 21 ], and diseases. Data Analysis The first and second authors performed the content analysis [ 19 ]. Initially, the authors individually read the contents of the interview transcripts in depth while referring to the contents of the health-check diaries. After reading them, they generated the content regarding the HSB from the scripts. They discussed the HSB content until reaching an agreement, leading to the final HSB content. Parametric data were analyzed using Student’s t-test, and categorical data were analyzed using the chi-squared test. Symptoms from the health-check diaries were categorized based on the International Classification of Primary Care-2. Their real HSB based on their diaries and the HSB based on the constructed questionnaire were categorized into two groups based on a previous study: lay care and professional care. Regarding lay care, whether or not the patients’ real and potential HSB were correlated was analyzed using the chi-squared test and Spearman r, and statistical significance was set with p = 0.05. Regarding professional care, the participants’ real HSBs could be affected by their symptoms’ duration and severity, and the participants with only self-limited symptoms may not use professional care [ 18 ]. Hence, correlation between patients’ real and potential HSBs was revealed by the percentage agreement between the results of the lists and diaries. The results of the repetition of the HSB list for lay and professional care were analyzed using Cohen’s kappa statistic. The other independent variables were categorized binomially: sex (male = 1, female = 0), work (in employment = 1, not employed = 0), smoking (yes = 1, no = 0), alcohol drinking (yes = 1, no = 0), higher educational level (more than graduation from high school = 1, no = 0), living conditions (with family = 1, living alone = 0), higher social support (having or relative having = 1, not relatively having or not having = 0), higher social capital (high [10 to 6] = 1, low [5 to 1] = 0), and higher socioeconomical state (high [rich, relatively rich, or not poor] = 1, low [relatively poor or poor] = 0). Regarding HLS-14, the participants were divided into two groups according to a total HLS of above or below the median. This time, the median was 49. Based on kinds of diseases, a Charlson Comorbidity Index score was calculated for each participant. This index measures the severity of patients’ medical conditions as it relates to the possibility of admissions and mortality [ 22 ]. Ethical considerations Participants were informed that the data collected in this study would be used only for research purposes. They were also informed about the aims of this research, how the data would be disclosed, and that their personal information would be protected. Thereafter, they provided written informed consent. Ethics approval: The study was conducted in accordance with the principles of the Declaration of Helsinki and approved by Unnan City Hospital’s Clinical Ethics Committee (approval number: 20190033). Results Phase 1: Instrument development There were 267 participants (121 from the clinics and 146 from the hospital) in Phase 1. The participants’ average age was 79.3 years (standard deviation [SD] = 6.8), and 38.2% were male. The collection rate of the diaries was 98.1% (262/267). A total of 214 participants had experienced symptoms. The total number of symptoms was 262. The most common was joint pain (L20), followed by headache (N01) and fatigue (A04) (Table 1 ). Of the participants, 86.3% (226/262) used lay care and 13.7% (36/262) used professional care to address these symptoms. Eighty-four codes were derived for the approaches from the diary sheets, and the most common code found was self-care (132/262), followed by self-medication (72/262), using primary care (32/262), and using complementary medicine (21/262). In the content analysis, eight subcategories of lay care and four for professional care were created. The lay care category consisted of doing nothing, self-care (changing lifestyles, sleeping, resting, and taking a bath), seeking information, consulting family and friends, consulting community members, using complementary medicine, using home medicine, and buying over-the-counter drugs. The category of professional care included consulting pharmacists, consulting primary care physicians, visiting medical institutions (other than primary care physicians), and visiting general hospital emergency rooms (including calling for an ambulance) (Table 2 ). Table 1 Codes of the symptoms and classification using the International Classification of Primary Care-2 Ranking Code number Category ICPC-2 1 53 Joint pain L20 2 45 Headache N1 3 36 Fatigue A4 3 26 Itchiness S2 4 20 Muscle pain L18 4 16 Diarrhea D11 5 15 Back pain L3 5 14 Vertigo N17 6 7 Numbness N5 7 6 Abdominal pain D6 7 6 Insomnia P6 7 5 Common cold R74 8 13 Others ICPC-2 = International Classification of Primary Care-2. Table 2 Items of the help-seeking behavior list and definition of each item Category HSB Definition Lay care Doing nothing No action Self-care (sleeping, resting, taking a bath) Moderating symptoms by changing usual behaviors Seeking information Collecting information about symptoms Consulting family and friends Asking for help from family and friends Consulting community members Asking for help from community members Using complementary medicine Using chiropractic treatment or osteopathy Using home medicine Using medicine that is present in the home Using OTC drugs Buying OTC drugs in drug stores Professional care Consulting pharmacists Asking pharmacists for treatment Consulting primary care physicians Visiting primary care physicians for treatment Visiting medical institutions other than primary care physicians Visiting medical institutions excluding primary care physicians for treatment Visiting the emergency room of general hospitals (including calling for an ambulance) Going to emergency rooms of general hospitals for treatment HSB = help-seeking behavior; OTC = over-the-counter. Phase 2: Testing the validity and reliability of the HSB list The number of participants who responded to the HSB list was 315 (169 from the clinics and 146 from the hospital) with a 100% collection rate. The participants’ average age was 77.7 years (SD = 8.2), and 46.0% were male. The Charlson Comorbidity Index scores for 33.9% (107/315) of the participants were greater than 5 (Table 3 ). In terms of validity, the results of the list and the diaries were correlated (Spearman p 0.704; p < 0.001). The most common behavior with mild symptoms, during this phase, was consulting with primary care physicians, followed by self-care and using home medicine (Table 4 ). The test-retest reliability for mild symptoms found kappa values of 0.836 for lay care and 0.808 for professional care. Table 3 Demographic characteristics of the participants Variable N = 315 Age (years), mean ( SD ) 77.71 (8.27) Sex (males), % 46.0 Smoking, % 40 (12.7) Work, % 140 (54.4) Living alone, % 41 (13.0) Higher education, % 149 (47.3) Higher social capital, % 168 (53.3) Higher social support, % 229 (72.7) Higher SES, % 259 (82.2) Higher HL, % 159 (50.4) Charlson Comorbidity Index, number (%) Score = 2 48 (15.2) Score = 3 62 (19.7) Score = 4 98 (31.1) Score = 5 67 (21.3) Score = 6 24 (7.6) Score = 7 12 (3.8) Score = 8 4 (1.3) Diseases, number (%) Hypertension 293 (95.2) Dyslipidemia 254 (80.6) Diabetes mellitus 53 (16.8) Chronic kidney disease 60 (19.0) Heart failure 31 (9.8) Cerebral vascular disease 21 (6.7) Cancer 19 (6.0) Hepatic disease 15 (4.8) COPD 13 (4.1) Asthma 12 (3.8) Myocardial infarction 8 (2.5) SD = standard deviation; COPD = chronic obstructive pulmonary disease; SES = socioeconomic state; HL = health literacy Table 4 Prevalence of help-seeking behavior for mild symptoms Mild symptoms HSB N Percentage Doing nothing 10 3.1 Self-care (changing lifestyles, sleeping, resting, taking a bath) 146 46.3 Seeking information 42 13.3 Consulting family and friends 126 40.0 Consulting community members 10 3.2 Using complementary medicine 27 8.6 Using home medicine 129 41.0 Using OTC drugs 97 30.8 Consulting pharmacists 15 4.8 Consulting primary care physicians 227 72.1 Visiting medical institutions other than primary care physicians 19 6.0 Visiting the emergency room of general hospitals (including calling for an ambulance) 17 5.4 HSB = help-seeking behavior; OTC = over-the-counter. Discussion This is the first study to develop a list for assessing the trend in choosing lay and professional care in HSB and verifying its validity and reliability. The two phases of the study were designed to confirm content validity through various forms of data collection and testing. This list can provide a stepping-stone for further research regarding HSB of individuals and health outcomes. Content validity of the list was examined through diaries of symptoms, review of previous studies, and one-to-one interviews. Content validity is vital for lists because it ensures the list accurately evaluates what the study intends to measure, which this study accomplished through a survey assessing patients’ real HSB, providing real situational evidence to various HSB choices [ 16 , 17 ]. Existing studies were also used when developing list items because they discuss the categorization and concepts of the severity of symptoms [ 16 , 17 ]. Furthermore, the one-to-one semi-structured interviews deepened the understanding of the behaviors, allowed for further inquiry into possible behaviors, and confirmed behaviors suggested in the analysis of the diaries and research reviews. The analysis exemplified the list’s high construct validity and reliability by comparing the real activities and results of the checklist and test-retest. Through this comparison, a strong correlation was found between the two; therefore, the list has high validity [ 17 ]. As the participants were allowed to simultaneously choose multiple items in the list, the correlation and test-retest were performed for both lay and professional care, and high reliability and validity in both categories were found [ 23 ]. The patients’ symptoms in this study were similar to those in previous studies, but the rate of using primary care physicians was higher and the rate of self-care was lower than other studies [ 16 , 24 , 25 ]. This finding may be due to the medical conditions of older patients in developed countries, especially rural Japan [ 15 ]. Older patients tend to have a variety of symptoms and may have difficulties managing those symptoms [ 14 ]. In addition, as many older people are isolated and live only with their partners without enough help, this can lead to a trend of depending on medicine. Opposingly, the rate of self-care and self-medication with mild symptoms (using home medicine and over-the-counter medicine) was high [ 1 ]. This finding may reflect the trend of older people changing their behaviors and being more motivated to take care of their health. This may be because older people can have vague/irregular symptoms in combination with aging, meaning that there are unavoidable symptoms accompanied by prejudices [ 24 , 26 , 27 , 28 ]. However, there has been no study on the relationship between HSB and health outcomes, as well as aging [ 29 , 30 ]. Future research should investigate this relationship and interventions for improving older people’s HSB should be developed. There are several limitations to this study. Regarding validity, although the content validity was clarified, the construct validity for professional care with mild symptoms was not clarified. The various presentations of mild symptoms, such as durations and timing, affect HSBs, making identifying real HSBs difficult. HSB can depend on the individual’s situation. Living environment can change HSB in terms of three factors: accessibility, availability, and affordability [ 31 , 32 ]. The setting of this study was rural, so these three elements may have been low, potentially causing minimal use of primary care and other medical institutions. As the list is comprehensive and contains various behaviors, it can be used in different settings, clarifying multiple types of HSB. Another limitation is the difference in health insurance between countries. Japan’s medical system is a free access system; thus, Japanese people can access medical institutions anytime and anywhere [ 33 ]. When applying this list to other countries’ settings, other possible behaviors should be considered based on the local medical systems. Conclusions This study clarified rural older people’s choices of HSB for mild symptoms. The HSB list for mild symptoms developed in this study has high validity and reliability in the Japanese context and can be used in various contexts to assess people’s HSB for mild symptoms. Abbreviations HSB: help-seeking behavior Declarations Declarations Not applicable Ethics approval and consent to participate Participants were informed that the data collected in this study would be used only for research purposes. They were also informed about the aims of this research, how the data would be disclosed, and that their personal information would be protected. Thereafter, they provided written informed consent. The study was conducted in accordance with the principles of the Declaration of Helsinki and approved by Unnan City Hospital’s Clinical Ethics Committee (approval number: 20190033). Consent for publication Not applicable Availability of data and materials All data generated or analyzed during this study are included in this published article. Competing interests The authors have no competing interests to declare. Funding The authors declare that no financial support was received for this research. Authors' contributions RO designed, collected and analysed data, and prepared and revised the manuscript. MS conceptualized, designed study, analysed data and prepared the manuscript. YR designed, collected and analysed data. TM analysed and revised the manuscript. CS analysed and revised the manuscript. All authors read and approved the final manuscript. Acknowledgements We would like to thank all the participants who took part in this research. References Cornally N, McCarthy G. 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Fam Pract. 2019;36(4):452-459. https://doi.org/10.1093/fampra/cmy084 Cite Share Download PDF Status: Under Review Version 1 posted Review # 2 received at journal 22 Mar, 2021 Reviewer # 2 agreed at journal 13 Mar, 2021 Review # 1 received at journal 19 Dec, 2020 Reviewer # 1 agreed at journal 01 Dec, 2020 Reviewers invited by journal 28 Nov, 2020 Editor assigned by journal 24 Nov, 2020 Submission checks completed at journal 24 Nov, 2020 Editor invited by journal 24 Nov, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-124413","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":6080578,"identity":"0c645bea-7506-4fbf-b687-4f53b0c99db9","order_by":0,"name":"Ryuichi Ohta","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIiWNgGAWjYJCCA4wNEgwGIEZChYQcWOQBUVrYGBgfPDhjYwwWSSBkDWMDA0gLs+HDtrTEBpAIPi3mM3IMD/zcYSFnLt/8TCKB7XD6/LDDD4G22MnpNmDXInMjx+Bg7xkJY8s2NjOJBJ7DuRtvpxkAtSQbmx3ArkVCIsfgMGObROKGYwxALRJALbMTQFoOJG4jrIX9m0SCweF0w9npH4jVwmNskJCQliAvnUPAFp5nBQd72ySMDY7lFD5IOGBjuEE6p+BAggEev7Anb/7ws61OzuDw8Q0Hf/6TkJefnb75w4cKOzlcWhgEEtAEDMAqDXAoBwF+dLPkG/CoHgWjYBSMghEJAK/ZZ57BE/zZAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0003-2593-091X","institution":"Unnan City Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Ryuichi","middleName":"","lastName":"Ohta","suffix":""},{"id":6080579,"identity":"45bc4712-3227-4436-9e16-91b149e06a9e","order_by":1,"name":"Mikiya Sato","email":"","orcid":"","institution":"University of Tsukuba: Tsukuba Daigaku","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mikiya","middleName":"","lastName":"Sato","suffix":""},{"id":6080580,"identity":"486885e9-3567-4627-b463-bc29e4719dae","order_by":2,"name":"Yoshinori Ryu","email":"","orcid":"","institution":"Unnan City Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yoshinori","middleName":"","lastName":"Ryu","suffix":""},{"id":6080581,"identity":"581d5258-0462-4985-95cc-5c83b4bcecb5","order_by":3,"name":"Jun Kitayuguchi","email":"","orcid":"","institution":"Unnan City","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Kitayuguchi","suffix":""},{"id":6080582,"identity":"79cfc347-0f48-4141-861c-c297103d1a47","order_by":4,"name":"Tetsuhiro Maeno","email":"","orcid":"","institution":"University of Tsukuba: Tsukuba Daigaku","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tetsuhiro","middleName":"","lastName":"Maeno","suffix":""},{"id":6080583,"identity":"7fa688de-e950-48eb-ba9f-97f2cc976aad","order_by":5,"name":"Chiaki Sano","email":"","orcid":"","institution":"Shimane University Faculty of Medicine Graduate School of Medicine: Shimane Daigaku Igakubu Igakuka Daigakuin Igakukei Kenkyuka","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Chiaki","middleName":"","lastName":"Sano","suffix":""}],"badges":[],"createdAt":"2020-12-08 16:51:38","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-124413/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-124413/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":13630896,"identity":"8fa79a77-e488-45ca-ba3a-a9cc063ffcd9","added_by":"auto","created_at":"2021-09-17 08:14:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":423485,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-124413/v1/d94a3b4a-3596-4dbb-aacb-1aa501bf608e.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eWhat resources do elderly people choose for managing their symptoms? Clarification of rural older people’s choices of help-seeking behaviors in Japan\u003c/p\u003e","fulltext":[{"header":"Introduction","content":" \u003cp\u003eHelp-seeking behavior (HSB) is a human behavior that sustains health and involves seeking treatment for symptoms. It is an essential behavior for maintaining peoples\u0026rsquo; health, and ideally each person should have appropriate HSB. This requires people to assess their symptom and its severity, use lay care to manage these symptoms, followed by professional care as needed [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Suitable HSB can connect people with appropriate care and enhance peoples\u0026rsquo; health in ways such as better quality of life [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. A balance of lay care and professional care is important for appropriate HSB [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Lay care is care provided by lay people, or those who have received no formal training and are not paid, such as self-care and care from relatives, friends, and self-help groups, while professional care refers to care provided by trained paid professionals, usually in a formal setting [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].The efficient usage of lay and professional care can reduce people\u0026rsquo;s inappropriate HSB [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHSB varies relative to healthcare resources. In urban areas, there are many medical resources, allowing for choice between various medical and healthcare professionals [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, citizens in rural areas lack adequate resources for medical care, leading to inappropriate HSB such as usage of medical care for mild symptoms [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Limited education among people living in rural areas may also affect HSB [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In addition, rural HSB needs to be improved by providing information and educational interventions of HSB from multiple perspectives as these people may also lack information about medical issues [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Although the Internet and social media have advanced, they are primarily used by young and middle-aged people. The elderly tend to obtain information from television and newspapers [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. A lack of information may lead to inappropriate HSB especially for mild symptoms [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Furthermore, it results in excessive usage of medical resources and undesirable results for citizens\u0026rsquo; health [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRural older people\u0026rsquo;s HSB for mild symptoms can be improved by continuously providing them with accurate information about their symptoms and healthcare [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Therefore, it is crucial to assess their HSB for mild symptoms to suggest modifications. Thus, comprehensive checklist of rural older people\u0026rsquo;s HSB choices, that is reliable and valid evaluating the rural older people\u0026rsquo;s HSB for mild symptoms should be constructed [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Also, HSB for mild symptoms can be assessed in terms of the relationship with their demographic. Currently, no research has clarified comprehensive checklist of rural older people\u0026rsquo;s HSB choices, that is reliable and valid, regarding rural older people\u0026rsquo;s HSB for mild symptoms. Therefore, this study aimed to create comprehensive choices that can accurately assess rural older people\u0026rsquo;s HSB for mild symptoms.\u003c/p\u003e "},{"header":"Methods","content":" \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eUnnan City, located in southeast Shimane Prefecture, Japan, is primarily covered by forest and is one of the most rural cities in Japan. A 2017 survey revealed the total population was 38,882 (consisting of 18,720 males and 20,162 females) and that the percentage of people over the age of 65 was 37.82%; this is estimated to reach 50% by 2025. Kakeya and Tai Clinic are rural clinics in Kakeya and Yoshida Town, the towns situated in the most northern part of Unnan City. Both clinics are about 30\u0026nbsp;km from Unnan City Hospital, the only general hospital in the city. Kakeya Clinic has five registered physicians, two nurses, and no admission facilities. Tai Clinic has three registered physicians, two nurses, and no admission facilities. All the physicians in both clinics are family medicine specialists. At the time of this study, Unnan City Hospital had 281 beds comprising 160 acute care beds, 43 comprehensive care beds, 30 rehabilitation beds, and 48 chronic care beds. There were 14 medical specialties, and the nurse-to‐patient ratio was 1:10 in acute care, 1:13 in comprehensive care, 1:15 in rehabilitation, and 1:25 in chronic care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThe participants in this study were patients over 65\u0026nbsp;years who attended Kakeya and Tai Clinic and Unnan City Hospital for regular health checkups. All participants lived in Unnan City. They were informed about this study via advertisements, and an explanation of the purpose of the research was included in the list and monthly health diary. Patients who could not read, write, or hear properly and patients with dementia were excluded from this study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePhase 1: Instrument development\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eMonthly health-check diary\u003c/strong\u003e \u003cp\u003eThe diaries consisted of a space for noting the date, patient\u0026rsquo;s blood pressure, existence of symptoms, kinds of symptoms, and how they managed the symptoms (i.e., HSB). The participants checked whether they had symptoms at the end of each day for one month. The clinic nurses collected the diary pages when the participants visited the clinic one month later. If there were unclear terms in their diary, the clinic nurses checked their symptoms and their approach to the symptoms in depth and wrote this on the diary page in red ink.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eOne-on-one interviews and a review of previous studies to confirm the content validity\u003c/b\u003e: To create a valid HSB list, participants\u0026rsquo; HSB was first transcribed based on the diaries. Next, purposive sampling was used to choose 39 participants (20 from the clinics and 19 from the hospital) to be interviewed about their potential HSB for mild symptoms to confirm content validity, in line with previous studies [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The Interview guides consisted of four questions based on the previous HSB research: \u0026ldquo;What kind of symptoms do you have in your usual lives?\u0026rdquo; \u0026ldquo;How do you act when you have mild bodily symptoms?\u0026rdquo; \u0026ldquo;Why do you act so?\u0026rdquo; and \u0026ldquo;Please describe your concrete experiences[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u0026rdquo; To define mild symptoms, previous research was referred to regarding HSB. Based on these findings, participants were shown examples of mild symptoms: mild fatigue, flu-like symptoms, joint pain, back pain, and mild headache [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The contents of the interviews were then recorded and transcribed verbatim so the first and second authors could review the interview and diary transcriptions based on the content analysis method [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Through this process, the list of options of potential HSB was finally constructed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003ePhase 2: Testing the validity and reliability of the HSB list\u003c/h2\u003e \u003cp\u003eThe participants were given the constructed list of options of their potential HSB. Multiple answers were allowed for each question. By comparing the answers on the list and the results for the HSB in the monthly diaries, the validity of the list was assessed. Lists were completed in the waiting room at the clinic and then collected by nurses. To confirm the reliability of the HSB list, all participants were provided with the constructed HSB list twice, ensuring test-retest reliability. The interval between the two rounds of list completion was one month. The participants\u0026rsquo; data were also extracted from the clinic\u0026rsquo;s electronic medical record and a questionnaire including age, sex, work conditions, exercise habits, eating habits, sleeping habits, smoking, habitual alcohol drinking, educational level, living conditions, social support [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], social capital (using a 10-point Likert scale: can rely on neighbors in communities to completely not rely on neighbors in communities) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], socio-economic state and health literacy (HLS-14) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], and diseases.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThe first and second authors performed the content analysis [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Initially, the authors individually read the contents of the interview transcripts in depth while referring to the contents of the health-check diaries. After reading them, they generated the content regarding the HSB from the scripts. They discussed the HSB content until reaching an agreement, leading to the final HSB content. Parametric data were analyzed using Student\u0026rsquo;s t-test, and categorical data were analyzed using the chi-squared test. Symptoms from the health-check diaries were categorized based on the International Classification of Primary Care-2. Their real HSB based on their diaries and the HSB based on the constructed questionnaire were categorized into two groups based on a previous study: lay care and professional care. Regarding lay care, whether or not the patients\u0026rsquo; real and potential HSB were correlated was analyzed using the chi-squared test and Spearman r, and statistical significance was set with p\u0026thinsp;=\u0026thinsp;0.05. Regarding professional care, the participants\u0026rsquo; real HSBs could be affected by their symptoms\u0026rsquo; duration and severity, and the participants with only self-limited symptoms may not use professional care [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Hence, correlation between patients\u0026rsquo; real and potential HSBs was revealed by the percentage agreement between the results of the lists and diaries. The results of the repetition of the HSB list for lay and professional care were analyzed using Cohen\u0026rsquo;s kappa statistic. The other independent variables were categorized binomially: sex (male\u0026thinsp;=\u0026thinsp;1, female\u0026thinsp;=\u0026thinsp;0), work (in employment\u0026thinsp;=\u0026thinsp;1, not employed\u0026thinsp;=\u0026thinsp;0), smoking (yes\u0026thinsp;=\u0026thinsp;1, no\u0026thinsp;=\u0026thinsp;0), alcohol drinking (yes\u0026thinsp;=\u0026thinsp;1, no\u0026thinsp;=\u0026thinsp;0), higher educational level (more than graduation from high school\u0026thinsp;=\u0026thinsp;1, no\u0026thinsp;=\u0026thinsp;0), living conditions (with family\u0026thinsp;=\u0026thinsp;1, living alone\u0026thinsp;=\u0026thinsp;0), higher social support (having or relative having\u0026thinsp;=\u0026thinsp;1, not relatively having or not having\u0026thinsp;=\u0026thinsp;0), higher social capital (high [10 to 6]\u0026thinsp;=\u0026thinsp;1, low [5 to 1]\u0026thinsp;=\u0026thinsp;0), and higher socioeconomical state (high [rich, relatively rich, or not poor]\u0026thinsp;=\u0026thinsp;1, low [relatively poor or poor]\u0026thinsp;=\u0026thinsp;0). Regarding HLS-14, the participants were divided into two groups according to a total HLS of above or below the median. This time, the median was 49. Based on kinds of diseases, a Charlson Comorbidity Index score was calculated for each participant. This index measures the severity of patients\u0026rsquo; medical conditions as it relates to the possibility of admissions and mortality [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003eParticipants were informed that the data collected in this study would be used only for research purposes. They were also informed about the aims of this research, how the data would be disclosed, and that their personal information would be protected. Thereafter, they provided written informed consent.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthics approval:\u003c/strong\u003e \u003cp\u003eThe study was conducted in accordance with the principles of the Declaration of Helsinki and approved by Unnan City Hospital\u0026rsquo;s Clinical Ethics Committee (approval number: 20190033).\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e "},{"header":"Results","content":" \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003ePhase 1: Instrument development\u003c/h2\u003e \u003cp\u003eThere were 267 participants (121 from the clinics and 146 from the hospital) in Phase 1. The participants\u0026rsquo; average age was 79.3\u0026nbsp;years (standard deviation [SD]\u0026thinsp;=\u0026thinsp;6.8), and 38.2% were male. The collection rate of the diaries was 98.1% (262/267). A total of 214 participants had experienced symptoms. The total number of symptoms was 262. The most common was joint pain (L20), followed by headache (N01) and fatigue (A04) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Of the participants, 86.3% (226/262) used lay care and 13.7% (36/262) used professional care to address these symptoms. Eighty-four codes were derived for the approaches from the diary sheets, and the most common code found was self-care (132/262), followed by self-medication (72/262), using primary care (32/262), and using complementary medicine (21/262). In the content analysis, eight subcategories of lay care and four for professional care were created. The lay care category consisted of doing nothing, self-care (changing lifestyles, sleeping, resting, and taking a bath), seeking information, consulting family and friends, consulting community members, using complementary medicine, using home medicine, and buying over-the-counter drugs. The category of professional care included consulting pharmacists, consulting primary care physicians, visiting medical institutions (other than primary care physicians), and visiting general hospital emergency rooms (including calling for an ambulance) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eCodes of the symptoms and classification using the International Classification of Primary Care-2\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRanking\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCode number\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eICPC-2\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eJoint pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eL20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHeadache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eA4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eItchiness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eS2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMuscle pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eL18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDiarrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eD11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBack pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eL3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVertigo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumbness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAbdominal pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eD6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInsomnia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCommon cold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eR74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eICPC-2\u0026thinsp;=\u0026thinsp;International Classification of Primary Care-2.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eItems of the help-seeking behavior list and definition of each item\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHSB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDefinition\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003eLay care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoing nothing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo action\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-care (sleeping, resting, taking a bath)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerating symptoms by changing usual behaviors\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSeeking information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCollecting information about symptoms\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsulting family and friends\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAsking for help from family and friends\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsulting community members\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAsking for help from community members\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUsing complementary medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUsing chiropractic treatment or osteopathy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUsing home medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUsing medicine that is present in the home\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUsing OTC drugs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBuying OTC drugs in drug stores\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eProfessional care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsulting pharmacists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAsking pharmacists for treatment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsulting primary care physicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVisiting primary care physicians for treatment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVisiting medical institutions other than primary care physicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVisiting medical institutions excluding primary care physicians for treatment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVisiting the emergency room of general hospitals (including calling for an ambulance)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGoing to emergency rooms of general hospitals for treatment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eHSB\u0026thinsp;=\u0026thinsp;help-seeking behavior; OTC\u0026thinsp;=\u0026thinsp;over-the-counter.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePhase 2: Testing the validity and reliability of the HSB list\u003c/h2\u003e \u003cp\u003eThe number of participants who responded to the HSB list was 315 (169 from the clinics and 146 from the hospital) with a 100% collection rate. The participants\u0026rsquo; average age was 77.7\u0026nbsp;years (SD\u0026thinsp;=\u0026thinsp;8.2), and 46.0% were male. The Charlson Comorbidity Index scores for 33.9% (107/315) of the participants were greater than 5 (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In terms of validity, the results of the list and the diaries were correlated (Spearman p 0.704; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The most common behavior with mild symptoms, during this phase, was consulting with primary care physicians, followed by self-care and using home medicine (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The test-retest reliability for mild symptoms found kappa values of 0.836 for lay care and 0.808 for professional care.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eDemographic characteristics of the participants\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;315\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years), mean (\u003cem\u003eSD\u003c/em\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77.71 (8.27)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (males), %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (12.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e140 (54.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving alone, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (13.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher education, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e149 (47.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher social capital, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e168 (53.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher social support, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e229 (72.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher SES, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e259 (82.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher HL, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e159 (50.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCharlson Comorbidity Index, number (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScore\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (15.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScore\u0026thinsp;=\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (19.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScore\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98 (31.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScore\u0026thinsp;=\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67 (21.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScore\u0026thinsp;=\u0026thinsp;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (7.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScore\u0026thinsp;=\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (3.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScore\u0026thinsp;=\u0026thinsp;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (1.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiseases, number (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e293 (95.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyslipidemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e254 (80.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (16.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic kidney disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 (19.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeart failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (9.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebral vascular disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (6.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (6.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatic disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (4.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOPD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (4.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsthma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (3.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMyocardial infarction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (2.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;standard deviation; COPD\u0026thinsp;=\u0026thinsp;chronic obstructive pulmonary disease; SES\u0026thinsp;=\u0026thinsp;socioeconomic state; HL\u0026thinsp;=\u0026thinsp;health literacy\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003ePrevalence of help-seeking behavior for mild symptoms\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMild symptoms\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHSB\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eN\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003ePercentage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoing nothing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-care (changing lifestyles, sleeping, resting, taking a bath)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e46.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeeking information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e13.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsulting family and friends\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsulting community members\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUsing complementary medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUsing home medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e41.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUsing OTC drugs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e30.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsulting pharmacists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e4.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsulting primary care physicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e227\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e72.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisiting medical institutions other than primary care physicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e6.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisiting the emergency room of general hospitals (including calling for an ambulance)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e5.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eHSB\u0026thinsp;=\u0026thinsp;help-seeking behavior; OTC\u0026thinsp;=\u0026thinsp;over-the-counter.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e "},{"header":"Discussion","content":" \u003cp\u003eThis is the first study to develop a list for assessing the trend in choosing lay and professional care in HSB and verifying its validity and reliability. The two phases of the study were designed to confirm content validity through various forms of data collection and testing. This list can provide a stepping-stone for further research regarding HSB of individuals and health outcomes.\u003c/p\u003e \u003cp\u003eContent validity of the list was examined through diaries of symptoms, review of previous studies, and one-to-one interviews. Content validity is vital for lists because it ensures the list accurately evaluates what the study intends to measure, which this study accomplished through a survey assessing patients\u0026rsquo; real HSB, providing real situational evidence to various HSB choices [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Existing studies were also used when developing list items because they discuss the categorization and concepts of the severity of symptoms [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Furthermore, the one-to-one semi-structured interviews deepened the understanding of the behaviors, allowed for further inquiry into possible behaviors, and confirmed behaviors suggested in the analysis of the diaries and research reviews.\u003c/p\u003e \u003cp\u003eThe analysis exemplified the list\u0026rsquo;s high construct validity and reliability by comparing the real activities and results of the checklist and test-retest. Through this comparison, a strong correlation was found between the two; therefore, the list has high validity [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. As the participants were allowed to simultaneously choose multiple items in the list, the correlation and test-retest were performed for both lay and professional care, and high reliability and validity in both categories were found [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe patients\u0026rsquo; symptoms in this study were similar to those in previous studies, but the rate of using primary care physicians was higher and the rate of self-care was lower than other studies [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This finding may be due to the medical conditions of older patients in developed countries, especially rural Japan [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Older patients tend to have a variety of symptoms and may have difficulties managing those symptoms [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In addition, as many older people are isolated and live only with their partners without enough help, this can lead to a trend of depending on medicine. Opposingly, the rate of self-care and self-medication with mild symptoms (using home medicine and over-the-counter medicine) was high [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This finding may reflect the trend of older people changing their behaviors and being more motivated to take care of their health. This may be because older people can have vague/irregular symptoms in combination with aging, meaning that there are unavoidable symptoms accompanied by prejudices [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. However, there has been no study on the relationship between HSB and health outcomes, as well as aging [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Future research should investigate this relationship and interventions for improving older people\u0026rsquo;s HSB should be developed.\u003c/p\u003e \u003cp\u003eThere are several limitations to this study. Regarding validity, although the content validity was clarified, the construct validity for professional care with mild symptoms was not clarified. The various presentations of mild symptoms, such as durations and timing, affect HSBs, making identifying real HSBs difficult. HSB can depend on the individual\u0026rsquo;s situation. Living environment can change HSB in terms of three factors: accessibility, availability, and affordability [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The setting of this study was rural, so these three elements may have been low, potentially causing minimal use of primary care and other medical institutions. As the list is comprehensive and contains various behaviors, it can be used in different settings, clarifying multiple types of HSB. Another limitation is the difference in health insurance between countries. Japan\u0026rsquo;s medical system is a free access system; thus, Japanese people can access medical institutions anytime and anywhere [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. When applying this list to other countries\u0026rsquo; settings, other possible behaviors should be considered based on the local medical systems.\u003c/p\u003e "},{"header":"Conclusions","content":" \u003cp\u003eThis study clarified rural older people\u0026rsquo;s choices of HSB for mild symptoms. The HSB list for mild symptoms developed in this study has high validity and reliability in the Japanese context and can be used in various contexts to assess people\u0026rsquo;s HSB for mild symptoms.\u003c/p\u003e "},{"header":"Abbreviations","content":" \u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHSB: help-seeking behavior\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDeclarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were informed that the data collected in this study would be used only for research purposes. They were also informed about the aims of this research, how the data would be disclosed, and that their personal information would be protected. Thereafter, they provided written informed consent.\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the principles of the Declaration of Helsinki and approved by Unnan City Hospital\u0026rsquo;s Clinical Ethics Committee (approval number: 20190033).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no financial support was received for this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRO designed, collected and analysed data, and prepared and revised the manuscript. MS conceptualized, designed study, analysed data and prepared the manuscript. YR designed, collected and analysed data. TM analysed and revised the manuscript. CS analysed and revised the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all the participants who took part in this research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCornally N, McCarthy G. Help-seeking behaviour: a concept analysis. Int J Nurs Pract. 2011;17(3):280-288. https://doi.org/10.1111/j.1440-172X.2011.01936.x\u003c/li\u003e\n\u003cli\u003eFox A, Reeves S. Interprofessional collaborative patient-centred care: a critical exploration of two related discourses. J Interprof Care. 2015;29(2):113-118. https://doi.org/10.3109/13561820.2014.954284\u003c/li\u003e\n\u003cli\u003eSirri L, Fava GA, Sonino N. 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Rural Remote Health. 2016;16:3553. Available: rrh.org.au/journal/article/3553.\u003c/li\u003e\n\u003cli\u003eFord JA, Turley R, Porter T, et al. Access to primary care for socio-economically disadvantaged older people in rural areas: a qualitative study.\u0026nbsp;PloS One\u003cem\u003e.\u003c/em\u003e2018;13(3). https://doi.org/10.1371/journal.pone.0193952\u003c/li\u003e\n\u003cli\u003eZou X, Fitzgerald R, Nie JB. \"Unworthy of Care and Treatment\": Cultural Devaluation and Structural Constraints to Healthcare-Seeking for Older People in Rural China. Int J Environ Res Public Healt. 2020;17(6). https://doi.org/10.3390/ijerph17062132\u003c/li\u003e\n\u003cli\u003eLiu Y, Chen Y, Cheng X, Zhang Y. Performance and Sociodemographic Determinants of Excess Outpatient Demand of Rural Residents in China: A Cross-Sectional Study. J. Environ. Res. Public Health.\u0026nbsp;2020;17:5963. https://doi.org/10.3390/ijerph17165963\u003c/li\u003e\n\u003cli\u003eKaneko M, Motomura K, Mori H, et al. Gatekeeping function of primary care physicians under Japan\u0026rsquo;s free-access system: a prospective open cohort study involving 14 isolated islands.\u0026nbsp;Fam Pract. 2019;36(4):452-459. https://doi.org/10.1093/fampra/cmy084\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"elderly patients, help-seeking behavior, Japan, lay care, professional care","lastPublishedDoi":"10.21203/rs.3.rs-124413/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-124413/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAppropriate help-seeking behavior (HSB) that involves lay and professional care may moderate the usage of medical resources and promote good health, especially among the rural elderly. However, there is little evidence regarding the rural elderly\u0026rsquo;s HSB choices for mild symptoms. Therefore, this study attempts to bridge this gap.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe participants were patients living in rural areas and over the age of 65, who attended Japanese clinics and general hospitals. In Phase 1, monthly diaries and one-on-one interviews about their mild symptoms and HSB were used to establish checklist items and assess content validity. Content analysis helped determine the items. In Phase 2, participants were asked to complete the checklist to measure HSB. The checklist answers and HSB mentioned in the diaries were compared to evaluate construct validity. Retests were conducted to examine the content\u0026rsquo;s reliability and test-retest reliability.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePhase 1 included 267 participants (average age\u0026thinsp;=\u0026thinsp;75.1 years, standard deviation [SD]\u0026thinsp;=\u0026thinsp;4.3; 50.1% male). The diary collection rate was 97.6%. Of the participants, 70.4% used lay care and 25.4% used professional care. Content analysis identified eight types of lay care and four types of professional care. Phase 2 included 315 participants (average age\u0026thinsp;=\u0026thinsp;77.7 years, SD\u0026thinsp;=\u0026thinsp;8.27; 46.0% male). In terms of validity, the results of the checklists and the diaries were correlated (Spearman p 0.704; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The most common behavior with mild symptoms was consulting with primary care physicians, followed by self-care and using home medicine. The test-retest reliability for mild symptoms found kappa values of 0.836 for lay care and 0.808 for professional care.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe list of rural older people\u0026rsquo;s choices of HSB for mild symptoms had high validity and reliability. Therefore, it can be used to assess the relationships between HSB and health conditions and the effectiveness of health promotion on HSB among rural elderly people.\u003c/p\u003e","manuscriptTitle":"What resources do elderly people choose for managing their symptoms? Clarification of rural older people’s choices of help-seeking behaviors in Japan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-12-10 20:11:33","doi":"10.21203/rs.3.rs-124413/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2021-03-23T00:00:00+00:00","index":2,"fulltext":"Recommendation: Reviewer's comments unavailable pending editorial decision\n"},{"type":"reviewerAgreed","content":"","date":"2021-03-14T00:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-12-20T00:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable pending editorial decision\n"},{"type":"reviewerAgreed","content":"","date":"2020-12-02T00:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-11-29T00:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-11-25T00:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-11-24T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-11-24T23:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"65405b77-23a4-469d-bd8a-fdde25903ecd","owner":[],"postedDate":"December 10th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":1410870,"name":"Health Economics \u0026 Outcomes Research"},{"id":1410871,"name":"Health Policy"}],"tags":[],"updatedAt":"2020-12-10T20:11:33+00:00","versionOfRecord":[],"versionCreatedAt":"2020-12-10 20:11:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-124413","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-124413","identity":"rs-124413","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}