Association between caregivers’ knowledge and care seeking behaviour for children with symptoms of pneumonia in six sub-Saharan African Countries

Our analyses were based on data from Multiple Indicator Cluster Surveys (MICS) conducted in sub-Saharan Africa. These nationally representative household surveys are conducted by national implementing agencies with the support of the United Nations Children’s Fund (UNICEF). MICS surveys collect statistically sound and internationally comparable data on a variety of topics related to maternal and child health, including knowledge of symptoms of childhood illnesses and care seeking behaviour for children under the age of five years [13, 14]. Sub-Saharan African countries were selected for inclusion in this study if they had a MICS conducted during or after 2010, the data was national representative, and the datasets were available upon the start of our analyses (August 2015). Information on knowledge of symptoms of childhood illnesses was obtained during interviews using the ‘individual women’s’ questionnaire, administered to women age 15 through 49 years. Data on care seeking behaviour were obtained via the ‘children under-five’ questionnaires, administered primarily to mothers of children under the age of five years. When the mother was deceased or living elsewhere, the questionnaire was administered to the child’s primary caregiver.

Sampling frames are usually based on the most recent national census and therefore do not include non-household populations; i.e., they exclude populations living in group quarters (e.g., hospitals, military barracks) and those living on the street. Usually, a two-stage cluster sampling approach is used; the first stage: select enumeration areas and do a listing of households, second stage: select households from list. While the surveys we used were conducted in different countries - and may therefore vary due to limitations in costs and practical considerations (including security) - all surveys ‘adhere to the fundamentals of scientific sampling, including complete coverage of the targeted population, use of suitable sample size, the need to conduct household listing and pre-selection of sample households’ [13].

For each country, we first assessed the proportion of caregivers (either mothers, or primary caregivers) of children under-five that mentioned one or both symptoms of childhood illnesses linked to pneumonia, i.e., fast and/ or difficulty breathing, as a reason to seek care. The specific interview question asked to caregivers was: “Sometimes children have severe illnesses and should be taken immediately to a health facility. What types of symptoms would cause you to take a child under the age of 5 to a health facility right away?” A subsequent probe question asked: “Any other symptoms?” The responses were categorized as: child is not able to drink or breastfeed; becomes sicker; develops a fever; has fast breathing; has difficulty in breathing; has blood in stools; is drinking poorly; any other (unspecified); and some countries included categories such as diarrhoea and/ or vomiting. We classified caregivers who were able to identify either fast or difficulty breathing as having knowledge of pneumonia symptoms. As responses were not categorized as “cough” or “chest in-drawing,” we were not able to include these symptoms in our analysis of pneumonia specific knowledge.

Third, we assessed which proportion of these caregivers brought their child to an appropriate health provider. The interview questions related to care seeking were: “Did you seek advice or treatment for the illness from any source?” “Where did you seek advice or treatment?” A subsequent probe asked, “Anywhere else?” We defined ‘appropriate’ health care provider as one working at either a private or public hospital, primary health care facility or any other government service, and who has undergone formal training and received accreditation, authorizing them to treat children with signs of acute respiratory tract infections. Once we knew which proportion sought appropriate care, we assessed if the caregivers who mentioned at least one pneumonia specific symptom as reason to seek immediate care – i.e., fast or difficulty breathing – were indeed more likely to seek care from these providers, as supposed to those who did not mention one of these symptoms.

We conducted our analyses using SPSS version 21. The data analysis was conducted by two independent researchers [CN and PH]. We first created a new dataset by merging the two (i.e., the ‘individual women’s’ and ‘children under-five’) data files, matching eligible cases for both surveys based on cluster, household and line number. For caregivers with more than one child under the age of five, we used the files of the youngest child - in the case of twins we kept the child that was mentioned last. We weighted the data using the sample weight variables. Cases with missing data (i.e., surveys which were partly completed, as well as missing variables needed for these analyses) were excluded from the analyses. We calculated the percentage of caregivers included in the merged dataset who reported fast or difficulty breathing as reasons to seek immediate care from a health facility. We then calculated cross tabulations and performed Chi-square tests to assess the association between care seeking and knowledge of at least one symptom (i.e., fast or difficulty breathing).

Based on the literature on care seeking, we included the following variables in the multivariate analyses: household wealth quintile (poorest, poorer, middle, richer and richest); residence (rural, urban); caregiver’s age (15–19, 20–24, etc.) and their level of education (none, primary, and secondary or higher); child age (<2 years, 2–5 years) and their sex (boy, girl); and the total number of children ever born (<2, 2–3 and 4+). When possible we also adjusted for geographical location (regions) and religion. With the categories for the last two variables being country specific, not always available, and – in some cases – sample size restrictions, we pre-defined some parameters: 1) the sample had to be large enough (≥10 cases per category); 2) geographical location had to refer to regions e.g., the North, East, South or West and not to any other groupings (i.e., provinces, or districts), and 3) we first assessed if we could include geographical location (regions), after which we conducted the same assessment for religion.

We performed a multivariate logistic regression for the dependent variable (care seeking from an ‘appropriate’ health provider) and the independent variables, in order to examine the association. We then calculated the adjusted odds ratios (ORs) with corresponding 95% confidence intervals (CIs).

Table 1 shows the samples per country, after merging the women’s and children’s datasets, with Nigeria as the largest sample (N = 16,242) and Sierra Leone as the smallest (N = 6,033). The vast majority of caregiver-child combinations included in the analyses across the six countries live in rural settings, and most of the caregivers have at least four children. The largest differences across the countries were found in levels of education, with most caregivers having had no education in Chad (73.8%), Sierra Leone (71.2%) and Nigeria (42.0%) and at least primary school in Malawi (69.6%), DRC (42.7%) and CAR (42.6%). The percentage of cases with symptoms of pneumonia (i.e., those for whom the mother or caregiver mentioned that their child had a cough and fast and/or difficulty breathing due to a problem in the chest in the past two weeks) ranged from 3.7% (n = 607) in Nigeria to 9.6% (n = 947) in Chad (Table 1). Hence, in the total population we had 4,163 cases with symptoms of pneumonia.

Of the two symptoms linked to pneumonia, caregivers were most aware of the symptom ‘difficulty in breathing’, ranging from 17.4% of the sample in Chad to 24.0% in CAR, see Table 2. Across all 6 countries around 30% (ranging from 29.2 - 32.9%) of caregivers were aware of at least one of the two symptoms. We characterised these caregivers as caregivers with appropriate knowledge of pneumonia symptoms. When assessing the percentage of caregivers who mentioned both symptoms, this ranged from 4.5% in Chad to 11.2% in CAR.

Table 3 shows the associations between knowledge of at least one symptom for pneumonia and care seeking from appropriate health care providers, also with adjustments for the predefined variables in a multivariate logistic regression model. Of children with symptoms of pneumonia in the previous two weeks, those living in Sierra Leone and Malawi were most likely (73.2% and 68.8%, respectively) to be brought to an appropriate provider. In Chad and CAR this was only 27.4% and 30.9%, respectively. Care seeking was only moderately better in Nigeria (41.9%) and DRC (44.2%).

In DRC, the odds of a child whose caregiver mentioned at least one symptom related to pneumonia as reasons to seek immediate care was 1.9 times higher (95% CI = 1.3-2.7, P ≤ 0.01) than the odds for a child whose caregiver did not mention one of the symptoms to have been brought to an ‘appropriate’ health provider during his or her last illness. The association remained largely the same after adjusting for wealth, residence, maternal age and education, the age and sex of the child, and number of children ever born (OR = 2.0, 95% CI = 1.3-3.0, P ≤ 0.01). A significant association was also found in Nigeria, where the odds of a caregiver with knowledge of symptoms was 1.6 times higher (95% CI = 1.1-2.2, p ≤ 0.01) as opposed to the odds of a caregiver without knowledge of symptoms to seek care from an ‘appropriate’ health provider. After adjusting for the pre-defined variables as mentioned for DRC, and for religion (Muslim, Christian) and geographical location (6 regions; north-east, north-west, south-south, south-east, south-west, north-centre) the OR increased to 1.9 (95% CI = 1.3-2.9, p ≤ 0.01). For the other four countries, the analyses revealed no significant association between knowledge and care seeking.

The main limitations of this study are linked to the fact that the reported prevalence, knowledge and care seeking patterns are based on questions to the primary caregiver. For example, the children with symptoms of pneumonia are based on caregivers’ perceptions of symptoms and their ability to recall events, which could lead to incorrect estimates [28]. In other words, if caregivers do not recognize the symptoms of children which really have pneumonia, the cases are not categorized as ‘children with symptoms of pneumonia’. In relation to this, we were not able to assess if knowledge of pneumonia specific symptoms lead to more accuracy in the recognition of pneumonia specific symptoms, subsequently leading to better identification of suspected cases, or, as the cases are not clinically validated as those requiring medical care, not seeking care might in some cases be justified. Also, we were not able to disaggregate the data by severity of the illness, or by the severity of symptoms (e.g., chest in-drawing), or if a child had multiple symptoms; all factors which are known to be associated with care seeking. Plus, as caregivers were not prompted about specific symptoms, it is possible that pneumonia specific symptoms just did not come to mind when interviewed, this could have led to under-reporting of these specific symptoms. Finally, we were not able to discern where caregivers learned about symptoms of childhood illnesses and whether or not they learned this after care seeking for the child’s last illness. A study from Nigeria [29] showed that only 23% of the caregivers received health information from the healthcare providers after being hospitalized.