CHAPTER II

REVIEW OF RELATED LITERATURE

This chapter presents the background information about the PhilHealth Primary

Care Benefit 1 (PCB1) Package, about the indigents and LGU sponsored members, their

personal profile, their knowledge about the PCB 1 Package, and their attitude towards

and utilization of the benefits and privileges instituted in the PCB 1 Package of

PhilHealth.

Philippine Health Insurance Corporation

The National Health Insurance Program (NHIP) administered by the Philippine

Health Insurance Corporation (PhilHealth) was established in 1995 with the passage of

Republic Act (RA) 7875. PhilHealth took over the Medicare functions previously

administered by the Philippine Medical Care Commission (PMCC) since 1972.

PhilHealth’s mandate is to provide health insurance coverage to all Filipinos. In

1997, it assumed Medicare functions for government workers from the Government

Service Insurance System (GSIS) and a year later, for the private sector workers, which

was previously administered by the Social Security System (SSS). In the same year,

PhilHealth started the Indigent Program. In partnership with Local Government Units

(LGUs), PhilHealth has enrolled millions of families who otherwise have no access to

health services. Since then, this program has been at the heart of PhilHealth’s program.
 20

The Philhealth PCB 1 Package is a program introduced by PhilHealth in support

to the Aquino Health Agenda to provide Universal Health Care for all Filipinos. It aims

to ensure that all Filipino have access to quality health services that are efficiently

delivered, equitably distributed, fairly financed and appropriately utilized by the informed

and empowered public.

The Primary Care Benefit 1 (PCB1) Package offers primary preventive services,

diagnostic examination and drugs and medicines in any facility accredited by the

corporation as PCB 1 Provider. The PCB 1 providers consist of any government health

facility and Out Patient Department of Municipal Health Officers/City Health Officers

has the capacity and human resources to deliver the said Program.

Primary Care Benefit 1 providers must provide obligated services to every target

clients including their dependents at least once a year. Among the obligated services are

free consultation, blood pressure measurement for non-hypertensive 18 years old and

above, clinical breast examination for females 25 years old and above, visual inspection

with acetic acid or Pap smear for females 25-55 years old with intact uterus, and body

measurements. Members with religious and cultural barriers may sign a waiver not to

avail of the obligated services like visual inspection with acetic acid wash.

Socio-Demographic Profile and Knowledge

The indigents and LGU sponsored program members were among the target

clientele of the PCB 1 Package. PhilHealth started this program way back 2012 to ensure

that the less privileged population of our country can have access to a quality health care.

Monitoring for compliance of this program has not been strictly enforces and many still
 21

did not understand fully the extent of the benefit’s they should avail. There is no literature

that has explored this topic but there are several studies done with regard to knowledge,

attitude and practice or utilization.

Age and Knowledge

Many findings regarding the relationship between age and knowledge have been

found conflicting. While some studies revealed no significant relationship between the

two variables Cortel (2007 and Italia (2012), other studies found significant relationship

between them Ang (2008) and Palmes (2010).

The study conducted by Cortel (2007) among nurses at Capiz Emmanuel Hospital

showed no significant relationship between age and knowledge. This was supported by

the study of Italia (2012) among the Senior Citizens in the Municipality of Leganes

which revealed that age is not associated with the senior citizens’ knowledge of the

Senior Citizens Law.

However, the study of Ang (2008) among mothers in Rural Barangay in Aklan

found that younger individual were likely to have greater exposure and knowledge to

modern health care services than older ones. The study reported that young ones place

more value on modern medicines than the old ones. This was also supported by the study

of Palmes (2010) among the faculty of West Visayas State University which found that

age had a significant bearing on the level of knowledge of the respondents. It revealed

that knowledge of an individual increases as they grow.

 22

Sex and Knowledge

Different reports have been made about the relationship of sex and knowledge.

Ciudad (2009), and Macato (2013) revealed that sex of the individual is significantly

related to their level of knowledge. On the contrary, findings of Palmes (2010), Macahilig

(2011) and Italia (2012) revealed no significant relationship between sex and knowledge.

The study of Ciudad (2009) among nursing aides revealed that sex had a bearing

on level of knowledge. Female nursing aides knew better about standard precautions on

the use of personal protective equipment than males. A similar finding was reported by

Macato (2013) on the utilization of child health services in Roxas City. The study found

that higher educational attainment achieved by the respondents influences the use of

services by increasing the individual’s decisions making power and increasing their

knowledge of health services.

On the other hand, the study by Macahilig (2011) among hypertensive patients

argued that an individual can acquire knowledge through other means other than formal

education and may be more aware of the health problems, know more about the

availability of healthcare services and the use this information more often and effectively

to maintain their health status. Similar study findings were revealed on the study of

Palmes (2010) among faculty of West Visayas State University and Italia (2012) among

Senior Citizens. Their studies revealed that there was no significant relationships between

the sexes of the respondents and their level of knowledge.

 23

Civil Status and Knowledge

Contradictory results on studies on the relationship between civil status and

knowledge have been reported. Cortel (2007), Bautista and Yap (2009) found on their

studies that civil status had a significant bearing on the knowledge of the indicial.

However, the studies of Marañon (2008), Ciudad (2009), and Palmes (2010) revealed that

civil status has no significant bearing on level of knowledge.

The study of Cortel (2007) among nurses at Capiz Emmanuel Hospital revealed

that civil status had a significant relationship and the level of knowledge, Likewise,

Bautista and Yap (2009) reported that married diabetic clients were more knowledgeable

about their diet regimen, exercise, and medication on diabetes than single clients.

The study of Marañon (2008) revealed that civil status of Central Philippine

University faculty had no significant bearing on their knowledge. Likewise, Ciudad

(2009) found that marital status of the nursing aides was not associated with the level of

knowledge on the use of personal protective equipment. This was confirmed in the study

of Palmes (2010) among faculty of West Visayas State University which found that

marital status was not significantly related with the level of knowledge on the treatment

aspect of colon cancer.

Educational Attainment and Knowledge

With regards to the educational attainment and knowledge, studies done by Cortel

(2007), Marañon (2008) and Macato (2013) revealed that educational attainment and

knowledge are not significantly related. On the contrary, Diaz (2008), Palmes (2010), and

Bautista and Yap (2009), found that educational attainment and knowledge are

significantly associated.
 24

Cortel’s study (2007) among nurses at Capiz Emmanual Hospital and Marañon

(2008) revealed that level of education of the respondents did not influence their

decisions to utilize screening for prostate cancer. This was supported by the study of

Macato (2013) among mothers enrolled in main barangay health stations which revealed

that educational attainment is not significantly related to their level of knowledge.

On the other hand, the study of Diaz (2008) among health practices of fathers in

child care, and Palmes (2010) among faculty of West Visayas State University showed

significant relationship between educational attainment and knowledge. Another study

conducted by Bautista and Yap (2009) on the faculty of West Visayas State University

reported that a lower level of education significantly affects the level of knowledge of the

respondents. The study concluded that respondent’s level of understanding can be related

to their level of education and somehow affect their decisions in the utilization of health

services.

Income and Knowledge

Studies reviewed on the relationship between income and knowledge revealed

conflicting results. Palmes (2010) and Italia (2012) found that income and level of

knowledge of their respondents are not significantly related. However this was refuted by

the studies of Diaz (2008) and Dadivas (2010) which showed that income played a role

on the level of knowledge of the respondents.

The study of Palmes (2010) among faculty members and that of Italia (2012)

among senior citizens revealed that the income earned of the respondents has no

significant bearing on their level of knowledge. Italia (2012) furthermore reported that
 25

regardless of the pension or salary earned by the respondents, their level of knowledge

remained the same.

In contrast, the study of Diaz (2008) among fathers in child health care and

Dadivas (2010) among caregivers in selected hospitals in Iloilo and Roxas City revealed

that income influenced their level of knowledge.

Socio-Demographic Profile and Attitude

Age and Attitude

With regard to the relationship between age and attitude, related studies found

conflicting results. The studies conducted by Chacko (2007), Lutz (2008), and Nagoya

(2010) reported that age was significantly associated with the attitude of the respondents.

On the other hand, studies conducted by Cortel (2007), Bautista and Yap (2009) and

Penaso (2010) revealed that age of an individual has no significant bearing on their level

of attitude.

Age influence the attitudes and decision of an individual to use health services

accordingly. Chacko et al. (2007). The study highlight that the older the age of an

individual, the more likely they are aware of their health status and that they are more

likely to consult health practitioner more often. Another study on Health Care Attitudes

and Service Utilization among African- Americans showed that the older the participants,

the more likely they would consult medical practitioner about his/her health issues. Lutz,

(2008). Nagoya (2010) also found that older respondents have negative attitudes towards

availment of antenatal care services. The older ones preferred to consult local healer than

to visit a health care centers. They also expressed negative attitudes on the new and
 26

modern health services, and they perceived them as threat to their old beliefs and

customs.

On the contrary the findings of Cortel (2007) among nurses at Capiz Emmanuel

Hospital and those of Penaso (2008) among male faculty members of Central Philippine

University, and those of Buatista and Yap (2009) among diabetic clients revealed that age

and attitude were not significantly associated with each other.

Sex and Attitudes

Related studies on the relationship concerning sex and attitude also have

conflicting results. Studies of Cortel (2007), Bautista and Yap (2009) revealed no

significant relationship between sex and attitude. On the contrary, the findings of Ciudad

(2009), Deloitte (2010), and Dieta (2010) revealed that sex and attitude was significantly

associated with one another.

The study of Cortel (2007) on adherence to Ethico-Legal standards of nursing

practice at Capiz Emmanuel Hospital revealed that sex and attitudes were not

significantly related. Similar findings were reported by Bautista and Yap (2009) on their

study on exposure to mass media, health teaching and educational materials among

diabetic clients.

The findings of Ciudad (2009) however, on the standard precautions of nursing

aide and those of Deloitte (2010) about health care consumers in Germany showed a

significant relationship between sex and attitude. A similar findings was reported by

Dieta (2010) in her study on newly hired nurses’ attitude and competence.
 27

Civil Status and Attitude

Related studies found conflicting results regarding the relationship between civil

status and attitude. The studies of Lutz (2008) and Macahilig (2013) revealed that civil

status had a significant bearing on the attitude of the respondents. On the other hand, the

studies of Palmes (2010) and Ozden (2011) debunked the findings, and revealed that civil

status was not significantly associated with the respondent’s attitude.

The study of Lutz (2008) on the health care attitude of African-Americans

revealed that married individuals had a positive attitudes towards health care and towards

seeking for consultation and availing of health services in health centers. Married

individuals were more than three times as likely as single individual to consult for

medical practitioner, especially when it comes to their children. This was supported by

the study of Macahilig (2013) among hypertensive patients in Kalibo, Aklan which

revealed that civil status play a significant role on the level of attitudes of that

respondents.

On the other hand, a study by Palmes (2010) among faculty members of West

Visayas State University revealed that civil status and attitude were not significantly

related with one another. Similar findings was reported by Ozden (2011) inn his study

among urban settlers in Japan on choosing a Health Care Plan. The study showed that

civil status of an individual did not affect their attitudes on choosing what kind of health

care plan he/she will avail.

 28

Educational Attainment and Attitudes

With regards to the relationship between educational attainment and attitude,

related studies also found conflicting results between the two variables. The study by

Diaz (2008) and Singson (2009) revealed that educational attainment has a significant

bearing on the level of knowledge and the attitudes of the respondents. In contrast, the

study of Duckett, Munro, Hunt, and Sutton (2013), showed that the attitude of

educational attainment of the respondents doesn’t affect their attitudes towards health

care provisions.

The study of Diaz (2008) on the attitudes and practices of fathers in child health

care revealed that educational attainment of the respondents and their level of attitude

towards child health care were significantly related. Similar findings were revealed by

Singson (2010) on the attitude towards health promoting lifestyle among rural health unit

diabetic clients. The study revealed that education emerged as one major determinant of

attitudes of women to use antenatal care services.

On the other hand, a study conducted in China showed that educational

attainment of the respondents did not affect the attitudes of respondents towards health

care provisions. Regardless of their level of education attained, the respondents believed

that the government will implement this heath care provisions equitably to all. Duckett,

Munro, Hunt, and Sutton (2013).

Monthly Family Income and Attitude

Related studies regarding the relationship between income and attitude also

revealed different results. Welschoff (2008), Aitken (2013), Duckett, Munro, Hunt,

Sutton (2013), and Nagoya (2010) found that income had a significant bearing on the
 29

attitude of the individual to avail of health services offered to them. On the contrary, the

study of Diaz (2008) and Kraft (2010) showed no significant relationship between

income and attitude of the respondents.

A study by Welschhoff (2008) among rural inhabitants of Malaysia revealed that

the poor income group in the society had positive attitudes towards health care though

they were more likely to use the traditional healer than the public system. Likewise in the

study of Aitken (2013) in India showed that the cost of treatment at a public healthcare

facility is two to nine times more affordable than that available at a private healthcare

facility, and is dependent on the nature of treatment (IPD, OPD–Chronic, OPD–Acute).

The economic burden of a treatment is significant for poor sector of society, e.g., each

episode of illness resulting in an IPD treatment costs them greater than their monthly

average household expenditure (Aitken 2013). Moreover, a study in China revealed that

people with low incomes – often rural dwellers – found it increasingly difficult to pay for

rapidly rising health care costs. Duckett, Munro, Hunt, Sutton (2013).

The family income proved to be one of the most significant predictors of attitudes

towards availement of Antenatal Care Services. Women who had high incomes were 95

% more likely to have obtained the services than women with low incomes. Nagoya

(2010).

On contrary, the study of Diaz (2008) among fathers doing child care revealed

that regardless of their income, their attitude towards child health care did not vary.

Similar finding was also reported by Kraft (2010) among working individuals with health

insurances. The study revealed that monthly income did not affect the attitudes of the

individual with regards to utilization of health services.

 30

Place of Residence and Attitudes

Findings on place of residence and the attitude were not also consistent. The

studies by Starrette (2004), Welschoff (2008), and Lutz (2008) revealed that distance

from the health facility is significantly associated with the level of attitudes of an

individual. However the study Pe. S (2012) reported otherwise.

A study by Welschoff (2008) on utilization of health service showed that physical

access has an impact on the attitude of an individual for service utilization. Attitudes

depend on spatial factors such as distance, which can be map or road distance, time

distance and patient mobility. Distance to health facilities was perceived to be more

important for women in India than the actual costs of services Lutz (2008). It is also

affirmed by the study of Starrette (2004) among Mexican-American that in rural areas

walking distance to health facilities is an important factor, because of the lack of

transport. Hence, a distance of 5 km, which means one hour walking, is considered to be

the maximum radius for .the time needed for reaching the facility and going back as well

as the time spent within the facility further constrain access since it means a loss of

income.

On the other hand, the study of Pe (2012) among pregnant women in Bugasong,

Antique revealed that place of residence was not significantly related to the attitude of the

respondents. The study revealed that access to and utilization of benefits among pregnant

women do not depend on how far the health care facility is.

Age and Utilization

As to the relationship between age and utilization, related studies also revealed

varied results. Singson (2010), and Macato (2013) reported that age of the respondents
 31

had a bearing on the extent of utilization of health care services. On contrary, Starrette,

(2004), and Italia (2012) found that age of the individual had no bearing on the way they

utilize their benefits and privileges of the health services.

A study conducted by Singson (2010) among diabetic clients revealed that the

older individual the more likely are likely to seek for health care services than the

younger ones. This was supported by the findings of Macato (2013) in her study on

extent of utilization of child health services which showed that the older the individual

are, the more experienced and knowledgeable they are about the health care services and

this improved their access and utilization of health care services.

On the contrary, the study of Starrette (2004) among Mexican-American elderly

revealed that the age of an individual has no significant bearing on to the utilization of

health services. This was supported by the findings of Italia (2012) among senior citizens

which showed that the age of the respondents had no bearing on their extent of utilization

of the benefits and privileges offered to the senior citizens.

Sex and Utilization

Conflicting findings were also found regarding the relationship between sex and

utilization. The studies conducted by Bolivar (2011) and Italia (2012) revealed that

gender bears no significant influence on the utilization of services provided for them. On

the other hand, the study of Fitzpatrick (2004), and Diesto (2007) debunked the findings

of Bolivar and Italia. They found that sex of the respondents had a significant bearing on

utilization.

The study of Bolivar (2011) among college students of Iloilo Doctors colleges

revealed that sex and utilization were not significantly related. Similarly, Italia (2012)
 32

found that sex of the senior citizens has no significant bearing on their extent to utilize

services and benefits offered to them.

Some studies revealed however, sex of the elderly is related to the extent of

utilization of the services offered as reported by Fitzpatrick (2004) in her study on

Barriers to Health Care Access. She reported that the gender of an individual plays a vital

role on how they will decide on utilization of the health care services intended for them.

The same findings of Diesto (2007) among high school students in private and public

schools in Iloilo City, She found that the gender of an individual is significantly related to

his/her extent of involvement on gangs practices.

Civil Status and Utilization

With regards to the relationship between civil status and utilization, findings of

related studies also vary. Alvaro (2013) showed that civil status and utilization are not

significantly related, while the studies of Lutz (2008) and Lee (2011) revealed significant

relationship between the two variables.

Alvaro’ (2013) study among women of reproductive age revealed the civil status

of the respondents is not significantly related to their level of utilization. On contrary,

Lutz (2008) found that married women were more likely than the single women to utilize

the services offered in the health care facility because the former have husbands who

supports them and help them pay for the expenses. The same findings was reported by

Lee (2011) among English teachers in Kang Nueng City, South Korea City. She revealed

that marital status of the respondents is significantly related to utilization.

 33

Educational Attainment and Utilization

On the relationship between educational attainment and utilization, review of

related studies revealed conflicting results. Charles (2010) and Italia (2012) revealed that

educational attainment and utilization of health care services were found to be

significantly related. The study of Kruck et al (2010) and Ingalla (2013) however,

discredit the findings and revealed no significant relationship between educational

attainment and extent of utilization.

Charles (2010) in his study on socio-cultural factors affecting attitude and

behaviour, regarding population and family issues in Nigeria reported that individuals

with low educational attainment were less likely to use the preventive services in the

health center and more likely to report poor health status than individuals with college

education. Similarly in the study of Italia (2012) among senior citizens showed a

significant association between level of education and utilization of services.

The study conducted of Kruck et al (2010) among residents of rural Tanzania

proved however, that there was no significant relationship between education and

utilization. The study revealed that education alone may not be sufficient to improve

health-care seeking behavior of a person. The study of Ingalla (2013) among senior

citizens in Aklan also found that the educational attainment of the respondents have no

direct effect on the use of health and social services.

Income and Utilization

Studies on the relationship between income and utilization also revealed

conflicting results. Alvaro (2013) and Ingalla (2013found that income and utilization are
 34

significantly related while, Penaflor (2009) and Italia (2012) found no significant

relationship between the two variables.

The study of Alvaro (2013) among women of reproductive age and that of Ingalla

(2013) among senior citizens in Aklan revealed that income and utilization are

significantly related. This implies that poverty does not only exclude people from the

benefits of health care system, but also restricts them from participating in decisions that

affect their health, resulting in greater health inequities. Income also determines the

ability of a person or a family as a whole to satisfy their need for healthcare.

The study of Penaflor (2009) among breast cancer survivors in Iloilo City

revealed that the monthly income of the respondents had no significant bearing on the use

of complementary and alternative medicines. The same findings was reported by Italia

(2012) among senior citizens in the municipality of Leganes. The study revealed that

income of the respondents did not affect their extent of utilization of services and benefits

intended for them.

Distance from the Health Facility and Utilization

With regards to the relationship between the distance from the health facility and

utilization, related studies also revealed varied results. Blazer (2005) and Ingalla (2013)

revealed that distance from the health facility and utilization are not significantly related.

However the study of Starrette (2004) and Pe (2012) showed a significant relationship

between the two variables.

The study of Blazer (2005) among older adults in North Carolina revealed that

people living in the urban places tend to utilize the health care service on the health

facility than those who live in the rural areas. His study also revealed that distance is an
 35

indicator of utilization of health services. It was supported by the study of Ingalla (2013)

among senior citizens in Aklan which revealed that utilization of services vary according

to their place of residence.

The study of Starrette (2004), however, on the uutilization of social services by

the Mexican-American Elderly revealed that distance from a health service facility has no

direct influence on how the people utilize the services. This was confirmed on the study

of Pe (2012) on the utilization of prenatal services of pregnant women in Bugasong,

Antique. Pe’s study revealed that regardless of the distance of the health care facility, the

respondents were eager to utilize the services such as prenatal care.

Knowledge and Attitude

Findings on the relationship between knowledge and attitude also vary. Penaso,

(2008), Bautista and Yap (2009) reported that knowledge and attitude were significantly

related, while the study of Marañon (2008) and Palmes (2010) found that knowledge had

no significant bearing on the respondents’ attitudes.

The study of Penaso (2008) among female faculty members of Central Philippine

University revealed that female respondents with high and average level of knowledge

regarding health screening had a positive attitude towards it. Bautista and Yap (2009)

affirmed this in their studies among diabetic clients. They found that the higher the level

of knowledge of the clients, the better their attitude.

On contrary, the study of Marañon (2008) among male faculty members of

Central Philippine University revealed that knowledge regarding the prostate screening

test was not significantly related to the respondents attitudes towards it. Similar findings
 36

was reported by Palmes (2010) among faculty members of West Visayas State

University.

Knowledge and Utilization

Studies on the relationship between knowledge and utilization revealed

disagreeing results. Starrette et al (2004) and Lee (2013) reported that knowledge and

utilization were not significantly related. On contrary, Marañon (2008) and Ciudad

(2009) revealed otherwise.

Study of Starrette et al’s (2004) study on the utilization of social services of

Mexican-American elderly found that knowledge had no significant bearing on the use of

social services. This findings was supported by Lee (2013) in her study on Perception and

Utilization of multimedia assisted teaching of English teachers in the academics in Kang

Neung City, South Korea. She revealed that knowledge was not significantly related with

utilization.

On the other hand, Marañon (2008) reported that elderly clients with cancer who

were knowledgeable of the disease process, itself are likely to utilize the health services

or any remedy that will alleviate what they feel or experienced. This was confirmed in the

study of Ciudad (2009) which found that knowledge about immunization and utilization

of it were significantly related.

Attitude and Utilization

On the relationship between attitude and utilization, conflicting results have also

been found. Bautista and Yap (2009), Castro (2011), and Italia (2012) found that attitude
 37

and utilization were significantly related. However, the study of Marañon (2008) shows

no significant relationship with each outer.

Study of Bautista and Yap (2009) among diabetic clients revealed that attitude of

diabetic clients was significantly related to their practice of their diabetic regimen.

Similar findings was also reported on the study of Castro (2011) among staff nurses in

private and public hospitals in Iloilo City revealed that the attitude of staff nurses towards

good practices in the prevention of nosocomial infection in the hospitals are significantly

associated with one another. This was also confirmed on the study of Italia (2012), that

the attitude of the Senior Citizens and the extent of the utilization of their benefits and

privileges are significantly associated.

However, the findings of Marañon (2008) revealed that despite the favourable

attitude of the male faculty of Central Philippine University still their compliance to

diagnostic examination to detect prostate cancer was low. Another study conducted by

Breimaier (2011) among graduate nurses in Austria in their utilization of research

findings, revealed that attitude of nurses tend to be negative and the top three named

barriers to their utilization were lack of time, lack of information/knowledge, and lack of

interest.

Summary of Findings

From the various articles, related studies and literature examined, conflicting

results were found regarding relationship between socio-demographic, such as

age, sex, civil status, educational attainment, income and the distance of place of

residence from the health care facility and knowledge and attitudes of the respondents

and between these variables and their utilization of health care services.
 38

While many studies showed that age, sex, civil status, educational attainment,

income and proximity from a health care facility were found to influence knowledge,

there were other studies which revealed the opposite.

Studies on attitude in relation to socio-demographic profile of the respondents

also have conflicting results. While some studies reported that age, sex, civil status,

educational attainment, income and place of residence were not significantly related to

attitude, there are studies that refute these findings and proved that these variables had

significant bearing on the respondents’ attitude.

Studies on the relationship between personal profile, such as age, sex, civil status,

educational attainment, income and distance of place of residence from a health care

facility and utilization of health care services also have contradictory results. Some

studies revealed that age influence utilization, while other studies showed no significant

relationship existed between them. With regards to sex, several studies showed that

females have greater concern than male, while some studies refutes, which proved that

both sexes utilized the services equally. Meanwhile studies on relationship between

educational attainment and utilization showed that individuals with a higher level of

education are more likely to utilize the services than those with lower education, but

other studies revealed otherwise. Studies on relationship between income and utilization,

showed that income was significantly related to utilization, but other studies contradicts

this.

Contrasting results were also found on the relationship between knowledge and

attitude. Some studies revealed the knowledge and attitude are not significantly related

though other studies showed otherwise.

 39

As to the relationship between the knowledge and utilization, disagreeing results

have been found, Marañon (2008) and Ciudad (2009) revealed that knowledge has a

significant bearing the utilization. On the other hand, Lee (2013) shows a no significant

relationship between knowledge and utilization.