Factors associated with caretakers’ knowledge, attitude, and practices in the management of pneumonia for children aged five years and below in rural Uganda

This study was nested within the Iganga Mayuge Health and Demographic Surveillance Site (IMHDSS) located in Eastern Uganda in 2019. The IMHDSS longitudinal population cohort was founded in 2005 and covers 65 villages in a clearly demarcated area within the Iganga and Mayuge districts. Currently, there are 101,302 residents from 17,429 households, with 60% living in rural and 40% in peri-urban areas. The IMHDSS catchment area includes 23 health facilities within the demographic surveillance area which include two general hospitals, 15 level II Health Centres (HCII) (11 public, 3 private-not-for-profit (PNFP) and 1 private-for-profit), 6 level III Health Centres (5 public and 1 PNFP), 1 level IV Health Centre (public) and over 20 private clinics. The cohort characteristics have been profiled elsewhere [16].

This was a cross-sectional study design.

A caretaker was defined as a person who was found to be in caring or regarded as a guardian of a child aged 5 years and below at the time of the study while basing on roles held. A minimum sample of caretakers of children aged five years and below was estimated using the Kish Leslie 1965 formulae [17].

The study population was obtained using systematic sampling Systematic sampling was used to select households with the eligible caretaker of a child below five years of age. Using data from the IMHDSS population-based cohort, all villages were grouped into 25 enumeration areas. Within each enumeration area, 26 households were systematically selected. In larger villages (> 250 households), the study team randomly chose a direction from the center of the village, randomly selected the starting household from the first five houses in that direction, and then systematically selected every fifth house until they reached the edge of the village. In villages with less than 250 households, the total number was divided by the desired number of households to determine the sampling interval. Caretakers of children aged five years and below from those households were interviewed. The villages represented both urban and rural settings to provide better representation of the population.

The data collection tool for the assessment of the factors associated with caretakers’ knowledge, attitude and practices towards management of Pneumonia among children aged 5 years and below was based on the questions adapted from published literature [18, 19]. The questionnaire was divided into 4 portions: the first portion deals with socio-demographic characteristics; the remaining three portions contain questions on the assessment of participants knowledge (12 questions), attitudes (17 questions) and practices (5 questions) of the caretakers. Knowledge, attitudes and practice scores of individuals were calculated to give the total knowledge, attitudes and practice score. The analysis of three modules was done on the basis of scalar-scoring method.

The section assessing knowledge (12 questions (3 questions from each of the subsections: risk factors, transmission, symptoms and treatment)) were answered on a basis of mentioning it and an additional “I don’t know” option. A correct answer was assigned 1 point and an incorrect/unknown answer was assigned 0 point. The total knowledge score ranged from 0 to 12. Caretakers’ overall knowledge was categorized, using Bloom’s cut-off point, as good if the score was between 80 and 100% (9.6–12 points), moderate if the score was between 60 and 79% (7.2–9.6 points), and poor if the score was less than 60% (< 7.2 points).

Questions assessing attitude (17 questions) were assessed using a Likert scale of ‘Strongly disagree (1)’, ‘Disagree (2)’, ‘Neutral (3)’, ‘Agree (4)’ and ‘Strongly agree (5)’. The overall attitude score was categorized using the same Bloom’s cut-off point, as good if the score was between 80 and 100% (68-85points), moderate if the score was between 60 and 79% (51–67 points), and poor if the score was less than 60% (< 51 points).

Practice of caregivers towards management of childhood Pneumonia was assessed by 5 questions using a 3-point Likert scale ‘Never (0)’, ‘Occasionally (1)’ and ‘Always (2)’. and the same Bloom’s cut off point was applied. Completed questionnaires were double entered using EPIDATA and imported into STATA 15 for cleaning and analysis.

Analysis consisted of graphical displays, descriptive statistics including frequency distribution, percentage, and the mean scores. A binary multiple logistic regression was used to assess the factors associated with caretaker knowledge, attitudes and practices. All the model point estimates with their 95% confidence interval were presented and interpreted.

Ethical approval was obtained from the Mildmay Research Ethics Committee (MUREC) (REF: 0312–2019). Informed consent was obtained from all participants in the surveys and data anonymity was ensured. All respondents were informed about the content and the purpose of the survey, the expected time for participating, and that all information would be kept confidential. They were then asked to consent to participate in the study. Data are stored on a password-protected computer after identifiers had been removed. This study was conducted in accordance with international ethical standards (Declaration of Helsinki 1964).

The management of pneumonia by caretakers in terms of knowledge attitude and practice as shown in Fig. 1. Twenty eight percent of the caretakers reported good knowledge in management of pneumonia, 36% reported moderate while 35% reported poor. Attitude was reported as good by 57% of caretakers while 74% of the caretakers reported good practice (Fig. 1).

77% of caretakers mentioned poor sanitation as a risk factor for Pneumonia, 61% mentioned incomplete or no immunisation dose and 53% mentioned not sleeping under an insecticide treated mosquito net as risk factors for Pneumonia. 7%% of the caretakers did not know any risk factor (Fig. 2).

The most commonly mentioned symptom was hot (elevated) body temperature, (mentioned by 95% of the caretakers) as shown in Fig. 2. This was followed by vomiting (58%), and running nose (56%).

65% of the respondents mentioned airborne spread, 54% mentioned direct contact, while 49% mentioned indirect contact and there were 5% of the respondents who didn’t know any way in which pneumonia is transmitted.

The most reported treatment for management of pneumonia was coartem (mentioned by 92% of the caregivers), followed by ORS solution (60%) and Amoxicilin (40%).

More than half of the respondents (57%) had good attitude towards the management of Pneumonia. 42% had moderate attitude and only 3 caretakers had poor attitude (Fig. 1). The mean attitude score was 68.3 (SD: 6.4). The caretaker attitude assessment is highlighted in Fig. 3. Almost four out of every ten caretakers disagreed or strongly disagreed with the statement that patients get all prescribed drugs from the facility (41%) while one in every ten disagreed with the statement that a child can access health care at any time (12%). Close to 19% of the care takers were either not sure or disagreed with the statement that the facility has everything needed for treatment while 14% did not think that the cost of treatment was fair.

Majority of the caretakers reported good practice (74.1%), 19.1% had moderate practices and only 6.8% had poor practice towards the management of pneumonia. The assessment of practice is highlighted by the indicators shown in Fig. 4. Around 33% of caretakers indicated that it is not easy to avoid sharing kitchen utensils. Close to 25% of the caretakers reported some level of difficulty in sneezing and coughing in tissue all the time, washing a child’s hand before eating, and washing hands before handling a child.

Caretakers that were aged 35 years and above had better knowledge about pneumonia (aOR: 1.63(95% CI:1.05 – 2.51)), and this was similar for married participants compared to unmarried (aOR: 1.82(95%CI:1.05 – 3.15)). Participants with higher education levels especially those with post-secondary (Tertiary) had more knowledge about pneumonia in this population compared to those who indicated none as their education level. The participants whose source of livelihood was salary/wage earners were more likely to know about pneumonia compared to those who were not working as shown in Table 2. For the determinants of attitude, it was married caretakers who had better attitudes compared to unmarried ones (aOR: 1.78 (95%CI:1.16 – 2.73)). This was also true for caretakers whose source of livelihood was a farmer (aOR: 2.50(95%CI: 1.38 – 4.52)) as well as salary/wage earners (aOR: 1.75(95%CI: 1.13 – 2.72)). Older caretakers showed a 32% probability of having a better attitude, although this was not statistically significant (aOR:1.32(95%CI:0.89 – 1.97)) as shown in Table 2. Exploring the determinants of caretaker practices in the management of pneumonia showed that a female caretaker was more likely to demonstrate appropriate practices compared to male caretakers (aOR: 2.77 (95%CI:1.23 – 4.37)). On the other hand, older caretakers were less likely to have proper practices compared to young caretakers, but this difference was not statistically significant as shown in Table 2. Education was another determinant of good practices where caretakers with Tertiary level of education had higher odds compared to those with no education. Being a Muslim caretaker was associated with having lower odds of being knowledgeable, having a good attitude, or applying appropriate practices in the management of pneumonia in this population compared to Christian caretakers but this was not statistically significant as shown in Table 2.

A third of the caretakers knew pneumonia as a common childhood illness. This is important since perceptions about how common a disease is; may have an influence on interpretation of severity, cause and actions taken by the caretakers in seeking health care [20]. The poor caretaker knowledge of the mode of transmission, risk factors, signs and symptoms and treatment of pneumonia, was similar to findings from studies done in Bangladesh and Mumbai where the majority could not recognize whether their child had Pneumonia or not [21‐24].

Among the Integrated Management of Childhood Illnesses (IMCI) standardized danger signs, incessant vomiting was the most cited followed by convulsions. However, no caretaker mentioned all the four standardized danger signs. Chest wall in-drawing/ fast breathing and hot body temperature were identified as signs and symptoms of pneumonia and was more than what was found in Mirpurhas, Pakistan where fast breathing & chest in-drawing were reported as symptoms for pneumonia by 59.4% of mothers [25]. Other studies also reported that participants correctly identified fast/difficult breathing as being suggestive of pneumonia [26‐28] and none of the caretakers mentioned all the danger signs. This is likely due to the low literacy levels among the caretakers in this study area where some of the caretakers could not clearly identify a single sign and symptom. This is an indication that more effort is needed in sensitizing caretakers to recognise the signs and symptoms of pneumonia and other childhood illnesses and the importance of seeking early medical care.

Caretakers with higher education levels had better knowledge about Pneumonia and other childhood illnesses. This could be explained by the caretakers’ exposure to different sources of information which is consistent with findings reported by Duke et al. [26], who reported that mothers with higher educational levels had better knowledge about Pneumonia and other childhood illnesses.

Older age was significantly associated with being knowledgeable about pneumonia. This is concurrent with study conducted in Kenya [18] and other studies conducted elsewhere [31, 28]. This could be because of increased exposure to information about pneumonia over time, higher levels of education, or greater personal or professional experiences with the disease. Being married was also associated with being good of knowledge about pneumonia concurrent with study conducted in Denmark that reported that married individuals have a decreased risk of being hospitalized with pneumonia compared with never-married, divorced, and widowed patients [29]. However, a study conducted in India did not find any significant association between being married and knowledge of pneumonia signs and symptoms [19]. This could be because the study was conducted in contextually different environment and assessed 8 factors such as simple signs and symptoms, assessment, prevention, causes and factors. Interventions should take into account the potential role of social support and social networks in promoting knowledge of pneumonia among caretakers of children [30].

Additionally, being a salary earner was associated with good being knowledgeable concurrent a prospective population-based study conducted in Brazil which found an association between higher income and lower risk of developing pneumonia [31]. Given that 42% of households in Uganda experience catastrophic health expenditures based on their monthly income for an episode of pneumonia in children under five years old [32] There is need to target education and awareness efforts towards populations who are less likely to be employed or earning a salary.

The household-specific factors of poor sanitation, overcrowding and use of biofuels were identified as risk factors of acquiring Pneumonia. Other studies reported poor hygiene practices as a risk factor for developing pneumonia [12], while household crowding was seen to double the likelihood of developing pneumonia [33] and, the use of solid fuel for cooking which causes indoor air pollution was also associated with increased risk of pneumonia [34].

On the other hand, a child-specific risk factor was poor immunisation status while caretaker-specific risk factors included low parent’s education level and smoking status of a parent. There are other studies which found poor immunisation status to be associated with an increased risk of developing pneumonia [33, 35], and lack of education for the mother or father also was associated with high risk of pneumonia [34, 36].

All the caretakers were able to state at least one treatment measure. Use of Antibiotics(like Amoxicillin, Cotrimoxazole and Gentamycin) was identified by caretakers for the treatment of childhood illnesses which is similar to studies where caretakers mentioned antibiotics (like Cotrimoxazole and Amoxicillin) as the commonly used treatment for pneumonia [37, 38]. The majority of caretakers mentioned Paracetamol, ORS and Vitamin A supplement which is similar to findings by other researchers where caretakers mentioned Paracetamol and supplements like ORS, and vitamin C as treatment for childhood illnesses in children five years and below [4, 39]. This was however different from Minz et al. who found out that Vitamin A supplement was perceived as unimportant in prevention and treatment of childhood illnesses [36].

Majority of the respondents in this study had good attitude similar findings were reported by Gundluru et al. [39]. This was however contrary to some studies which reported unfavorable caretakers’ attitude [14, 40]. Patients get all prescribed drugs from the facility as expected since most of the care givers sought care/treatment at public health facilities that offer free services. In other situations caretakers were frequently advised to buy drugs, needles or infusion fluids outside the health facility [14]. There was a significant relationship between marital status and attitude towards care seeking which is consistent with Alene et al. who reported that married mothers had an increased likelihood of seeking health care, unlike those mothers who were not living with their husbands [41]. This finding is probably due to the fact that caring for a child by oneself can be socially and financially burdensome compared to sharing responsibilities. Similar to good knowledge, the study also found an association between being a salary earner and having good attitude of caretakers regarding management of pneumonia as with other studies [19, 32] Most of the respondents in our study agreed that the cost of care/treatment is fair and favorable. This is expected since majority sought care at government health facilities in which care/treatment is offered free of charge. This was however different for Hildenwall et al. [14] as well as Bakare et al. [15] who found an existing financial constraint to care-seeking for sick children. Bakare et al. [15] further reported that this financial barrier was related to the purchase of drugs after a diagnosis had been made.

In the case of health care seeking, almost half of the respondents agreed that patients waited for a long time to receive health care which agrees with Hildenwall et al. [14] findings that the patients waiting time before being attended to was generally longer at hospitals. c More respondents agreed that healthcare providers who treated sick children had good attitude and they were respectful which was contrary to the findings by Hildenwall et al. who argued that some caretakers stated indifference among health care providers as well as rude reception [14]. A similar conclusion was reached at in Nigeria by Bakare et al. who reported that although caregivers in Jigawa and Lagos accepted and valued the care provided to them at primary health care facilities, there were accounts of dissatisfaction with the health workers’ attitude [15].

Being Muslim, female and a peasant farmer were significantly associated with good practices of caretakers regarding management of pneumonia. This consistent with studied conducted in contextually setting that found religion [42, 43] gender [44, 45] and occupation [46, 47] as important determinants for good practices for caretakers regarding management of pneumonia. Practice by caretakers was good because they always brought children for immunization when it was due which differed from other studies which found out that practice among caregivers was unsatisfactory [37]. Others have argued that, even with good immunization uptake, there were cases of missed doses of vaccines where children aged five years and below were either partially immunized or had never been immunized [35, 39]. Most caretakers always provided treatment to sick children as directed by health care providers a few reported that they occasionally or never provided treatment to sick children as directed. Similar findings were reported by Athumani et al. in a study conducted in Dar es Salaam [48], where most of the mothers ceased giving medication to children before dose completion.

The caretakers always promptly took their children to health facilities whenever they got ill. This is an indicator that women in this community are able to make good judgement and take appropriate actions towards healthcare-seeking for children. This was contrary to other studies that reported a delay in care seeking for ill children and attributing it to absence of the father who is considered the ultimate decision maker in the home as well as the influence of neighbors, friends and relatives who give suggestions as to what type of illness the child is suffering from [14, 15]. Even when the woman was able to identify the problem early enough, she would still be constrained by limited power and ownership of financial resources in the household which means that she still needs to consult with the husband before any action can be taken [15]. In other instances, the healthcare was only sought when the disease was perceived to be severe but most caretakers reported difficulty finding transport to go to the hospital [14]. Distance from the health facility, lack of belief in allopathy, financial constraints, poor recognition of severity of illness or danger signs, lack of family support and the primary decision maker regarding care seeking during an illness in the family being the father [39] were some of the barriers to prompt seeking of health care.

Adherence to hospitalization schedules for sick children as guided by health care providers was prominent, with a few cases occasionally or never adhering to given schedules. In another study, some caretakers reached a health care provider and still withdrew the child from initiating care due to a lack of money for continued care and the anticipation of high cost of transporting a dead body [14].

There were limitations to this study including relying on self-reported answers, which may be subject to recall and reporting bias. There was also the possibility of unidentified predictors or confounders regarding attitude and perceptions of caretakers about illness and health seeking behavior. Further research is needed to address these limitations.

Comprehensive interventions for increasing symptom recognition and improving health-seeking behavior are needed. Improving health literacy will have a significant impact on the reduction of childhood mortality. Women empowerment and counselling of family members is crucial to reduce childhood mortality.

Engagement of fathers for their involvement in childcare including education of danger signs especially when teaching mothers during antenatal visit sessions and during immunization visits.