Knowledge and reported practices of men and women on maternal and child health in rural Guinea Bissau: a cross sectional survey

The study was conducted in the two rural districts of southern Guinea Bissau (Quinara and Tombali) in which the EPICS trial is being implemented. Villages in the region were considered eligible for the trial if they were believed to have a population of approximately 300 inhabitants. The villages were mapped and enumerated during the maternal birth history baseline survey. Clusters were formed from one or more villages in order to create an average population of 350 per cluster. This process resulted in 241 villages being organised into 146 clusters for inclusion in the trial [14]. This baseline study of health knowledge and practice was conducted in 31 of these villages after the clusters had been identified but before they were randomised into control and intervention arms. The villages were selected on the basis of their accessibility (in the rainy season, when this study was conducted, some of the villages are inaccessible). The selected villages included those that had majority Fula (13), Beafada (10) and Nalu (5) populations. These are ethnic groups that normally identify themselves as Muslim. Two villages had Susu populations and one had Balanta population as majority.

In each selected village, 10 households out of those that had already been mapped were randomly selected for this study. Within each household, one woman who was a primary carer of a child aged five or under and one man who lived in the same household as the woman (most commonly her husband) were selected for interview. If a visited household had more than one eligible woman and/or man, the ones who were interviewed were randomly selected.

A fully structured questionnaire (Additional file 1) was developed and interviews were carried out by trained field workers who were supervised. The questionnaire -- which was in part based on questions from DHS surveys - collected information on knowledge and reported practices on the key indicators affecting child survival [3]. It was arranged into seven sections on household characteristics, respondent characteristics, health knowledge, pregnancy and delivery, vaccination status, treatment-seeking behaviour and household observation. Section one was completed with the woman and man together. Sections two, three and parts of six were completed with both the woman and man, interviewed separately. Sections four, five, parts of six and seven were completed only with the woman. Sections one and two had questions with only one possible answer. The other sections had two types of question: those for which only one answer could be given and those for which more than one answer was possible.

The questionnaire was piloted in two different villages in southern Guinea Bissau and revisions were made before the survey was conducted. These villages were excluded from the survey. A team of six field workers -- recruited from Bissau - and one field supervisor were provided with intensive classroom and field-based training as well as a detailed manual of survey guidelines. Field workers conducted the survey in Kriol or, where necessary, directly or through translation in appropriate local languages.

Characteristics of the households and of the interviewed women and men were tabulated. These included background characteristics of the households and demographic characteristics of the respondents by gender. Descriptive statistics for continuous variables included the mean, standard deviation, median, and range and for categorical variables the numbers and percentages. The number of correct answers given to the health knowledge and practice questions and their percentage distribution were tabulated by items and by gender (as appropriate).

An overall health knowledge score was derived by summing the total number of correct responses given to the fifteen health knowledge questions in section three of the questionnaire. Questions with more than one possible correct answer were weighted by the inverse of the total number of correct answers so that no single question contributed more than one point out of fifteen to the score. Factors affecting health knowledge scores were investigated using simple linear regression models. Gender was used as a single binary predictor. Education was categorised into primary (grade 1-6), secondary (grade 7-9), higher (grade 10-12) or Koranic education. Ethnicity was included in the models as Balanta, Beafada, Fula, Nalu, Mandinka, Susu and Bijagos, or other. Age and an indicator of household crowdedness (the number of people per room within the house) were used as continuous variables. Robust standard errors were used to allow for clustering within villages. The final multiple linear regression includes gender and ethnicity and other factors which either had a statistically significant effect on obtained health knowledge score themselves or confounded the effect of gender and/or ethnicity.

This study was approved by the ethics committees of 'The Centre for Coordination of the Research of the Ministry Of Health' in Guinea Bissau (NCP-021/2007) and the London School of Hygiene and Tropical Medicine (5173).

The general characteristics of the 310 households are presented in Table 1. An average of 11 people and 3 children aged under-five lived in each household. An average of 2.5 people shared a room. This table also includes fieldworkers' observations on household facilities. In 295 households (95%) a bed net was observed in the place where it was said the youngest child sleeps (data not in table). 82% of households had a hand washing facility close to where the food is prepared, but only 17% had soap to wash the hands with. 81% of the households had a latrine.

Table 2 presents the demographic characteristics of women and men interviewed for this study as well as their education and literacy level. In 216 households the interviewed man was the husband of the woman (data not shown in the table). On average, women were much younger than men (mean age of 27.9 years versus 40.7 years for females and males respectively). The majority of respondents were Fula or Beafada. The distribution of women's ethnicity was similar to men. On average, women had lower education levels than men and 65% of women had never attended school compared to 18% of men. Eighty three percent of women and 29% of men could not read the sample sentence.

Table 3 summarises the health knowledge of the interviewees by gender for each of the questions asked. For questions in which only one answer could be given, the number and percentage of interviewees who gave the correct answer is shown. The number and percentage of interviewees giving various numbers of correct answers are provided in the table for questions with more than one correct answer. Knowledge on the prevention and management of diarrhoea was low. Around half of respondents knew that a child with diarrhoea needs to drink more fluids than normal. About the same number recognised a packet of oral rehydration salt (ORS) when it was shown to them. However, only 34% of women and 36% of men knew that a baby aged under six months who has diarrhoea should be given breast milk followed by ORS. Likewise, knowledge on the prevention of malaria was low and 46% of women and 68% of men knew that malaria is spread through mosquito bites. Over 56% of women and 44% of men could not name any antimalarials that are used to treat malaria. Only 21% of women and 33% of men knew that a child taking chloroquine for malaria should be treated for three days, even if they feel better (i.e. they must complete treatment). Very few women (12%) and men (29%) stated that they had ever heard the term (pneumonia) and only one woman could give a specific symptom of pneumonia. Nobody knew about the use of antibiotics for treating pneumonia. Whilst the majority of respondents had heard of HIV/AIDs, very few knew that measles can be prevented by vaccination.

Simple linear regressions (Table 4) showed that women on average scored one point less on health knowledge than men (p < 0.001), with an overall mean of 5.60 (SD = 0.14) and 6.58 (SD = 0.14) respectively. People with higher levels of education achieved substantially higher scores (p < 0.0001). Although the number of people living in each room in a household reduced the knowledge score, this reduction was neither substantial nor statistically significant (p = 0.15). The highest knowledge scores were achieved by Nalu (66 respondents) and Balanta (30 respondents), however, the effect of ethnicity was not statistically significant (p = 0.8). With each year increase in age the score is increased by 0.03 (p = 0.003). Multiple regressions revealed that the apparently lower knowledge score for women was the result of the confounding effect of education level. In the final model, once the effect of gender is controlled for age, education level and ethnicity, women score 0.1 points higher than men and the effect of gender becomes statistically insignificant (p = 0.7). The effect of age and education level estimated in this final model did not materially change compared to their effects in the simple regressions. The effect of ethnicity remained statistically insignificant in the multiple regression.

Mothers were also asked questions on exclusive breastfeeding and risk signs during pregnancy. Thirty two percent knew that complementary feeding should start at 6 months and 66% could not identify any risk signs.

Ninety three percent of women stated that they had received antenatal care (Table 5). The majority of these checkups were conducted in clinics or hospitals (88%). Most deliveries occurred at home with only around 23% in a health facility. Health professionals attended 24.4% of deliveries. In 68% of deliveries, a razorblade was used to cut the umbilical cord and 79% of women stated that the equipment used was sterilised. The umbilical cord was reported to be cleaned with alcohol by 17% of women. Only 25% of women reported commencing breastfeeding immediately or within one hour of the birth.

Vaccination coverage for the youngest child of each of the women interviewed is summarised in Table 6. Of the 310 women only 245 had a vaccination card for their youngest child, thus the analysis could only be done for these children. 88% of children aged one week and over had received their BCG vaccination. Around 90% of children aged 6 weeks and over had received their OPV1 and DPT1 vaccinations. Vaccination coverage falls as the children get older. 56% of children who had a vaccination card received vaccinations in regional clinics.

Treatment-seeking behaviour of women and men was quite different. Fifty percent of women stated that they would seek help from another parent if a child was sick. In contrast, 60% of men stated they would seek help from a clinic or a hospital if a child was sick (Table 7). Men and women gave similar reports for the places where medicines for children are normally bought.

Women were also asked whether they can decide by themselves whether or not a seriously ill child should be taken for medical treatment and 71% stated that they can (data not shown in table).