Analysis of Health-Seeking Behavior Factors in Coronary Heart Disease Patients

Introduction: Indonesian Research of Basic Health 2019 show that 1.5% of Indonesia's population suffers from coronary heart disease (CHD). Coronary heart disease has an impact on all aspects of the patient's life. Good health-seeking behavior is expected to prevent the severity from getting worse, and the risk of complications, up to death. This study aims to analyze the relationship between knowledge, attitudes, perceptions about health-illness and the ease of access to health service providers with health-seeking behavior in CHD patients. Methods: This study used a correlational descriptive design with a cross sectional approach. The population is CHD patients who are registered in the 3 work areas of the Gresik District Health Center. A large sample of 80 patients, using a purposive sampling technique. This study used questionnaires of health-seeking behavior in CHD patients, knowledge, attitude, perception about health-illness, and a questionnaire to measure the the ease of access to health service providers. Data analysis used the Spearman Rho test. Results: Major partial CHD affects patients aged 46-55 years and of good sex. There is a relationship between knowledge and health-seeking behavior in CHD patients (p = 0.001 and r = 0.367), there is a relationship between attitudes and health-seeking behavior in CHD patients (p = 0.000 and r = 0.737) and there is a relationship between perceptions of illness and health-seeking behavior in CHD patients (p = 0.001 and r = 0.361). Conclusion: The higher the knowledge and perceptions about illness and health, the more supportive the patient's attitude will be, and the better the health-seeking behavior in CHD patients. It is hoped that education and assistance can be given to CHD patients so they are more aware of the importance of appropriate treatment behavior.


INTRODUCTION
Coronary Heart Disease (CHD) become the most common cause of death from cardiovascular disease in the world, one of which is in Indonesia. East Java is one of the provinces contributing to mortality from coronary heart disease. The highest mortality and morbidity rates are caused by delays in treatment efforts, accuracy and speed of diagnosis, and treatment by doctors (Amrullah et al., 2022). Coronary heart disease (CHD) is affecting blood vessels conditions it can cause plaque to build up in wall artery, therefore artery become more cramped and as a result blood flow become slow (Huriani et al., 2022). The results of previous studies showed that patients felt angina symptoms such as chest pain or discomfort in the chest, felt a heavy chest pressure without direct treatment of the pain. From the results of the survey, the lack of knowledge, attitudes, perceptions of illness, distant from health care facilities become obstacles in determining the right treatment (Putri, 2019). The results of Basic Health Research show that 1.5% or 15 out of 1,000 Indonesians suffer from coronary heart disease (Amarullah & Rosyid, 2021). East Java ranks 4th with the most CHD sufferers in Indonesia.
Data from the Indonesian Ministry of Health states that the prevalence of coronary heart disease in East Java based on the results of Basic Health Research shows 1.5% or 15 out of 1,000 Indonesians suffer from coronary heart disease . East Java ranks 4th with the most CHD sufferers in Indonesia. Data from the Indonesian Ministry of Health stated that the prevalence of coronary heart disease in East Java based on a doctor's diagnosis was 0.5% or around 144,279 sufferers (Upadhana et al., 2021). Based on the results of a preliminary study conducted by researchers at several Puskesmas in Gresik, coronary heart disease is included in the top 10 most diseases registered at the Puskesmas. More than 150 patients were diagnosed and registered at the Puskesmas as coronary heart disease patients during 2021-2022. The estimated number continues to increase by 10% and accounts for 5% of deaths each year. The results of interviews conducted in March 2023, in 10 patients at the health centre, 50% stated that routine treatment was not enough to expedite health services. Distance and cost of health service providers, attitudes, perceptions and lack of knowledge are the main obstacles for patients in determining the right treatment. The doctor's diagnosis is 0.5% or around 144,279 sufferers (Upadhana et al., 2021). Based on the results of a preliminary study conducted by researchers at several health centres in Gresik.
CHD is characterized by the accumulation of plaque in the coronary arteries that is increasingly widened, thickened and hardened (calcified). this causes narrowing of the lumen of the coronary arteries (75% occlusion), and results in decreased blood flow and oxygen supply to the heart. Risk factors for coronary heart disease are divided into two major groups, namely: non-risk factors that can be modified or prevented and risk factors that can be modified or prevented. Risk factors for coronary heart disease that cannot be prevented include age, family history, gender. Risk factors that can be prevented include: hypertension, smoking, hyperlipidemia, diabetes mellitus, passive physical activity, and obesity (Simsek et al., 2021). Treatment of CHD involves long-term pharmaceutical therapy. As a disease that cannot be cured and must always be controlled, regularly consumed can prevent dangerous enlargement of blood clots, and has poor therapeutic results, such as uncontrolled hypertension, hyperlipidemia, arrhythmias, heart failure which can cause sudden cardiac arrest (Rossello et al., 2015).
The large number of CHD patients who do not carry out the routine behavior of seeking the right treatment can pose various risks of complications up to death. Factors of knowledge, attitudes, perceptions about illness and health, distance and costs for health services can be factors that influence a person's decision making in determining treatment according to the theory of Health Seeking Behavior. Based on this background, the researchers wanted to conduct research related to the factors that influence health-seeking behavior in patients with CHD.

Study Design
This study used a quantitative descriptive research design method with a cross-sectional approach.

Population, Samples, and Sampling
The population used is 100 coronary heart disease patients who have been recorded for the last 3 months, namely January-March 2023 at the primary health center in Gresik Regency. A large sample of 80 patients, using a purposive sampling technique. The independent variables are the knowledge factor, the attitude factor, the perception about illnes, and the ease of access to health service providers. Dependent variable of this study was health-seeking behavior in CHD patients.

Instruments
The data collection instruments used were questionnaires on health-seeking behavior in CHD patients, knowledge, attitude, perception about illness, and the ease of access to health service providers. Questionnaires, all modified from existing questionnaires from previous research (Rahman, A. N. & Prabamurti, P. N., & Riyanti, 2016). The results of the validity and reliability tests showed that all question items were declared valid and reliable (r ≥ 0.25 and Alpha-Cronbach ≥ 0.6).

Procedure
After previously obtaining patient data from the health center, the researcher will meet with the patient, to be asked for their willingness to be a respondent. Researchers distributed questionnaires by giving questionnaires to respondents in each health center, who had been selected according to the criteria using a questionnaire sheet which contained an explanation regarding the introduction of the researcher, research objectives, guarantees of confidentiality of information provided by respondents, informed consent forms, filling instructions questionnaire, and question points according to the topic to be studied

Data Analysis
The data is analyzed by looking at the frequency and percentage. Key data analysis was carried out using the Spearman's rho correlation statistical test with a significance degree of ρ ≤ 0.05. Data analysis to know the relationship between knowledge, attitude, perception, and the ease of access to health service providers with health-seeking behavior in CHD patients.

Ethical Clearance
This study was carried out by passing an ethical review from the health ethics review commission Faculty of Dentistry, Universitas Airlangga and obtaining approval for the study protocol number 520/HRECC.FODM/V/2023.  The results of the data collection in Table 1 show that of the 80 respondents, most of them were suffered by patients aged 46-55 years (42.5%). More than half of the female sex suffered from CHD (62.5%). Almost all CHD patients are married (90%). Most CHD patients are residents who have husbands and children (40%). The majority of CHD sufferers are residents with families < 5 people in one house (57.5%) and live < 1 km from health care facilities (51.3%). It is also known that almost half of CHD sufferers are high school graduates (42.5%), with more than half of sufferers not working (53.8%). CHD patients have relative income which is marked the same as expenses. The majority of CHD patients have income and expenses below the minimum wage for Gresik Regency (<4.5 million per month) (82.5%). Almost all CHD patients receive health insurance (BPJS) (98.8%), with 33.8% of CHD patients having been underdiagnosed since 1 year.

RESULTS
Based on table 2, it was found that more than half of CHD patients had sufficient knowledge related to health-seeking behavior, namely 60 people (75%) and 20 other people (25%) had less knowledge. The data shows that more than half of the CHD patient respondents have a supportive attitude to seek appropriate treatment, namely 55 people (68.8%). There were patients who did not support the attitude of seeking appropriate treatment, namely 2 people (2.5%). Based on the data, it is known that the majority of CHD patients have an adequate perception of good illness, as many as 48 people (60%). There were also CHD patients with a high level of perception of pain, namely 31 people (38.8%). Almost all CHD patients have easy access to health services, namely 77 people (96.3%). However, there are still CHD patients who still have difficulty accessing health services, namely 3 people (3.8%). Data shows that more than half of CHD patients have good health-seeking behavior, as many as 51 people (63.8%). There are also CHD patients who still have poor health-seeking behavior, namely 29 people (36.3%).
Table 2 also shows that there were 51 (63.8%) patients with good health-seeking behavior, with 43 (53.8%) of them having sufficient knowledge and 8 (10.0%) others having insufficient knowledge. The results of data analysis using Spearman Rho, obtained a value of p = 0.001 (p <0.05) and a value of r = 0.367. The p value on the results of the analysis is less than 0.05, which indicates that there is a relationship between knowledge and health-seeking behavior in CHD patients. The value of the correlation coefficient (r) means that there is an adequate relationship or moderate and one-way correlation between the positive variables, the higher the patient's knowledge, the better the health-seeking behavior and vice versa. There were 51 (63.8%) patients with good health-seeking behavior and a supportive attitude. The results of data analysis using Spearman Rho, obtained a sign of p = 0.000 (p <0.05) and a value of r = 0.737. The p value on the results of the analysis is less than 0.05, which indicates that there is a relationship between attitude and health-seeking behavior in CHD patients. The value of the correlation coefficient (r) means that there is a strong relationship and direction positive correlation between variables, the more it supports patient attitude, the better the treatment behavior and vice versa. There were 51 (63.8%) patients who had good health-seeking behavior, 26 (32.5%) patients had high perceptions, 24 (30%) patients had sufficient perceptions, and only 1 (1.3%) patient have low health perceptions. The results of data analysis using Spearman Rho, obtained a value of p = 0.001 (p <0.05) and a value of r = 0.361. The p value on the results of the analysis is less than 0.05, which indicates that there is a relationship between perceptions about the disease and health-seeking behavior in CHD patients. The value of the correlation coefficient (r) means that there is an adequate relationship or moderate and one-way correlation between the positive variables, the higher the patient's perception, the better the health-seeking behavior and vice versa. There were 51 (63.8%) patients who had good health-seeking behavior, 49 (61.3%) of them had easy access and 2 (2.5%) others had difficult access to health services. The results of data analysis using Spearman Rho, obtained a value of p = 0.556 (p > 0.05). The p value on the results of the analysis is more than 0.05 which indicates that there is no relationship between Ease of Reach Health Service with health-seeking behavior in CHD patients.

DISCUSSION
The results of this study indicate that there is a relationship between knowledge and health-seeking behavior in coronary heart disease (CHD) patients. The relationship between the two variables has a direction of correlation which is quite strong and the relationship is moderate. The higher the level of patient knowledge, the better the health-seeking behavior for CHD patients. Most of CHD patients have a sufficient level of knowledge and behavior seek good treatment. Only a small proportion of patients have a low level of knowledge and poor health-seeking behavior.
In line with the results of the study, that knowledge is one of the factors that influence a person's health-seeking behavior or health-seeking behavior (Salasi et al., 2021). The knowledge gained will influence behavior in the utilization of health services. Knowledge is a very important part in shaping a person's behavior cognitively, because the encouragement of something in the form of material about something that is elicited by object responses can be in the form of action. Because knowledge is a person's first step in determining attitudes and behavior (Menap et al., 2023). Strengthened by the results of the study, there is a significant relationship between knowledge and health-seeking behavior. As the theory put forward, that knowledge is an important factor that makes it easier for someone to bring up behavior. According to other experts, they say that knowledge about illness and disease can be used as a national base group to utilize health services, the higher the level of public knowledge about the disease, the higher the utilization of health services (Sormin & Amperaningsih, 2016).
In the results of this study, the relationship between knowledge and treatment behavior in CHD patients was included in the sufficient or moderate category. This is because there are still respondents who have a sufficient level of knowledge, but healthseeking behavior is included in the less category. Researchers assume that there are other factors that influence knowledge both from within oneself and from outside to be manifested in the form of appropriate treatment behavior. Most of the respondents have entered early old age, namely 46-55 years and the majority have junior high school education (junior high school, high school/equivalent). Respondent factors may experience difficulties/limitations in receiving information, to overcome the results of counseling or counseling related to the importance of treatment can be done to increase the knowledge of CHD patients The results of this study indicate a relationship between attitude and health-seeking behavior in coronary heart disease (CHD) patients. The relationship between the two variables has a strong correlation direction and a strong relationship. The more supportive the patient's attitude, the better the treatment behavior for CHD patients. Most of CHD patients have attitudes and behaviors that support seeking good treatment. However, there are still patients who have less health-seeking behavior.
In line with the results of previous research, that there is a significant relationship between attitude variables and health-seeking behavior (Bakar et al., 2023). Attitude predisposes many evaluations to determine the way individuals act. A person's attitude can change if he gets additional information about an object, such as through persuasion or pressure from social groups. However, real action is not only determined by attitude, but by various other external factors. Attitude is not the same as behavior, and behavior does not always reflect a person's attitude, because it often happens that someone shows actions that are contrary to attitude (Bakar et al., 2023)& (Menap et al., 2023). Other results suggest that attitude is a series of beliefs about something to influence a person's way of thinking and acting, so if a person has beliefs about what is seen as true about health then a person will be able to determine which attitude will maintain his health or improve his health (Hayden, 2022).
Attitude is a person's closed response to certain stimuli or objects, which already involve the opinion and emotion factors concerned, so that attitude involves thoughts, feelings, attention, and other psychological symptoms (Notoatmodjo, 2010). The three components that make up attitudes (Wawan & Dewi, 2010). There are the cognitive component, related to knowledge, views, beliefs are things related to people's perspective on attitudes. Second, the affective emotional component related to pleasure or dislike attitude. The last component is the behavior itself. Environmental factors are also a factor that influences a person's behavior. Each individual grows and develops in a different environment, this causes different information about something obtained. That information can be the basis for beliefs about the consequences of behavior about something that must be as well as various obstacles that prevent the behavior of something, because environmental factors include factors that influence a person's attitude (Mendrofa, 2021).
In this study the relationship between attitude and health-seeking behavior has a strong correlation. The results showed that more than half of the respondents had a supportive attitude towards appropriate medical behavior. In the formation of this supportive attitude, knowledge, beliefs and emotions play an important role.
Researchers assume that the majority of respondents are married and live with family status, getting one of the driving factors for the formation of the right attitude in determining health-seeking behavior. Motivation and support from the family to achieve recovery can become a belief which then influences the attitude of internal CHD patients to seek appropriate treatment.
The results of this study indicate that there is a relationship between perception about illness and health-seeking behavior in coronary heart disease (CHD) patients. The relationship between the two variables has a fairly strong direction of correlation and a moderate or moderate relationship. The higher the patient's perception of sick patients, the better the treatment behavior for CHD patients. Many CHD patients have high perceptions of health and good health-seeking behavior.
In line with the results of previous research that there is a significant relationship between perception of disease and health-seeking behavior. Respondents with high perceptions tend to have better health-seeking behavior 14 times compared to respondents with low perceptions (Thariq, 2019). Strengthened by the results of previous research that there is a significant relationship between perception variables and health-seeking behavior (Rahman, A. N. & Prabamurti, P. N., & Riyanti, 2016). The results of the study almost all respondents perceived that they would get cured if they went to health services. According to Jordan and Sudarti quoted from Rahman, that people's perception of pain is influenced by elements of past experience and socio-cultural elements. Everyone has a different perception even though observing the same object (Rahman, A. N. & Prabamurti, P. N., & Riyanti, 2016). Healthy disease is one one factor that influences one's health-seeking behavior after good knowledge and a supportive attitude (Mendrofa, 2021). The patient's perception of a healthy disease is a representation of the patient's cognitive and emotional response to his health condition, good awareness of the consequences of the disease, awareness of time treatment, disease identification he does not have an emotional response to illness (Dewi & Nisa, 2019).
In this study, the relationship between perceptions about illness and health-seeking behavior in CHD patients was included in the sufficient or moderate category. This is presumably because the respondent feels that the illness he is currently experiencing is not life threatening or not severe enough. The average experience of respondents about the majority of CHD <1 year diagnosed can form the perception that prevention of disease severity can still be done through medication.
The results of this study indicate there is a relationship between the ease of access to health service providers with the health-seeking behavior of coronary heart disease (CHD) patients. This is in line with the results of previous research, that there is a significant relationship between the ease of access to health service providers with healthseeking behavior (Mommana Ali Rathore et al., 2021;Salasi et al., 2021). In contrast to the results of previous studies which showed a significant relationship between access to services and utilization of health services (Rumengan et al., 2019). Difficult distances can be an obstacle for individuals to find and come to health care facilities. On the other hand, people are reluctant to travel long distances for treatment because of existing minor illnesses (Rahman, A. N. & Prabamurti, P. N., & Riyanti, 2016). In addition, the costs required for treatment include not only the drugs to be used but also travel costs to health care facilities (Widayanti et al., 2020).
In this study, although the average patient lives not far from the nearest health facility (< 1 km) and almost all of them have health insurance, this does not necessarily affect health-seeking behavior for CHD patients. Divorce handling behavior is not only related to ease of access, but also public awareness of the importance of health is still low. Distance and costs to health care facilities do not directly influence respondents' behavior in seeking health services (Mommana Ali Rathore et al., 2021). Researchers assume that even though distance and cost to health care facilities are included in the ease of access, there are still many patients who are not aware of the importance of good medical behavior.

CONCLUSION
Patients with sufficient knowledge tend to understand more about the treatment options they will undergo. Patients with a supportive attitude tend to be able to determine appropriate treatment behavior for themselves so that health improvements can be achieved. Patients with high perception tend to be more aware of the severity of their disease so they know the importance of taking the right medication and adherence. Awareness of the patient in carrying out treatment may be another factor that influences this factor. Ease of access and cost do not necessarily affect health-seeking behavior in CHD patients.
CHD is increasingly aware of the importance of choosing and taking the right steps for treatment, considering that CHD is a mandatory disease to keep it under control and requires a long treatment time. Further research can be developed using other variables or methods that can be predictors of health-seeking behavior in CHD patients.