Healthcare Seeking Behavior of Mothers of Under-five Children With Febrile Illness and Associated Factors in Uyo Metropolis

doi:10.21203/rs.3.rs-4612862/v1

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Research Article

Healthcare Seeking Behavior of Mothers of Under-five Children With Febrile Illness and Associated Factors in Uyo Metropolis

https://doi.org/10.21203/rs.3.rs-4612862/v1

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Background

The under-five mortality rate which is an index of population health continues to be high in sub Saharan Africa, Nigeria and Akwa Ibom state of Nigeria which is the setting for this study. The healthcare seeking behaviour of mothers is an important determinant of illness outcome in children. Thus, the objective of this study was to assess the percentage of mothers of febrile under five children exhibiting appropriate healthcare seeking behaviour and the factors that predict this behaviour.

Methods

This quantitative study was carried out using a self-administered/online structured questionnaire which elicited sociodemographic information from mothers aged 18–49 years with under-five children who had had a fever in the four weeks prior to the study. The variables were subjected to statistical analysis to test for association between appropriate healthcare seeking behaviour and various sociodemographic variables and to identify significant predictors of appropriate healthcare seeking behaviour.

Results

Three hundred and twenty mothers/caregivers were recruited into this study. Only 12.5% of the mothers exhibited appropriate healthcare seeking behaviour. Multivariate analysis identified increasing levels of educational attainment (aOR = 0.18, p = 0.002), increased family size ≥ 7(aOR = 7.03, p = 0.02), increasing average monthly family income (aOR = 3.44, p = 0.027) and the reason proffered for going to the health facility which was to prevent worsening of the condition (aOR = 11.72, p = 0.021) as significant predictors of appropriate healthcare seeking behaviour.

Conclusion

The level of appropriate healthcare seeking behaviour in mothers/caregivers in this study was abysmally low. Social determinants of health amongst other factors were found to be significant predictors of healthcare seeking behaviour.

Under-five

children

healthcare seeking behaviour

mothers/caregivers

Under-five (U5) children represent an especially important part of the paediatric age group. These are children aged 0–59 months who not only constitute the most vulnerable group within the paediatric age bracket but also among the general population. The under-5 mortality rate (U5MR) has been used as an index of child health and the health of populations globally and, by extension, their health care service delivery. (1)

Although the global U5MR has been on the downward trend over the past two decades, Sub-Saharan Africa continues to have the highest U5MR in the world (2) with Nigeria, having one of the highest rates in Sub-Saharan Africa at 97/1000 live births (2) and Akwa Ibom state in particular having the highest U5MR in the south-south region of the country i.e., 98/1000 live births. (3)

The leading causes of death in the under-5 age group remain diarrhoeal diseases, lower respiratory infections, neonatal causes, and Malaria with many of these childhood illnesses manifesting with fever as a principal symptom and sign. (4) Fever is the most frequent complaint in children presenting in outpatient and emergency departments in the United Kingdom (5–7) while in a study done in Ilesa, Nigeria, fever constituted 48.8% of all complaints of children presenting at the health center. (8) Thus, fever is a principal manifestation of infections in under-5 children in our environment.

Fever in the paediatric age group is subject to variable definitions not only because of physiologic influences such as time of the day, age (infants and young children have higher temperatures), activity levels and the menstrual cycle amongst others (9) but also variability arising from differences in sites of body temperature measurement. However, for clinical and research purposes, fever in children can be defined as a core temperature ≥ 38⁰C. (10)

For most mothers/caregivers in the developing world, fever in their children is usually assessed by palpation. This method of fever determination is at best highly subjective and unreliable though different researchers have obtained varying results. (11–13) Assessment of fever by mothers using palpation (touch) may be influenced by certain factors such as lack of availability of thermometers, parental education, or the lack of it and habit (Rosenbloom et al., 2020). (13) This method of fever assessment by mothers/caregivers becomes important as it is a precursor to determining the course of action to take in seeking healthcare for their children which ultimately affects childhood morbidity and mortality.

Healthcare seeking behavior (HCSB) has been defined as the process by which an ill individual accesses the formal healthcare sector. (14) It differs from health-seeking behavior, which refers to 'the sequence of remedial actions that individuals undertake to rectify perceived ill health’. (15) Healthcare seeking behavior may be appropriate or inappropriate with several researchers defining appropriate HCSB as presenting a febrile child to a formal healthcare facility within 24–48 hours of the onset of febrile illness. (16–19) Thus, HCSB is a complex interplay of factors that can affect a caregivers’ ability to seek and access formal healthcare facilities during the febrile illness of their children.

These factors include socioeconomic, personal, and demographic factors.(20) Examples of personal factors shown to be associated with HCSB include maternal/caregivers' age, level of education, presumed knowledge of the disease condition and perception of disease severity. (18, 21, 22) Demographic factors such as urban versus rural dwellings, distance to the health care facilities and even the season of the year during which the febrile illness occurs i.e., rainy season versus dry season and socioeconomic factors such as level of income and occupation have all been found to act as determinants of HCSB of mothers. (18, 20, 23–25) With this complex interplay of factors influencing HCSB, it became necessary to assess the percentage of febrile under-five children accessing prompt and adequate care within the last four weeks prior to the study and to investigate the factors which influence the healthcare-seeking behavior of mothers of these under-5 children with febrile illness in Uyo metropolis.

This cross-sectional study was carried out in nursery schools within Uyo metropolis which is the capital city of Akwa Ibom state in Nigeria. It is located at latitude 5.05 and longitude 7.93 at an elevation of 45 meters above sea level. It has an estimated population of 3,920,208. (26)

Sampling and recruitment of participants/data collection

Ten schools were randomly selected from a list of schools obtained from the state ministry of Education (27), two from each of the major streets in Uyo city namely Oron road, Aka road, Ikot Ekpene road, Abak road and Nsikak Eduok road. This was to ensure even representation of nursery schools within Uyo metropolis. Nursery schools were selected since they were places where the study population could be readily accessed.

The study population consisted of women of childbearing age between 18–49 years with under-five children in the selected nursery schools who have had a fever within the last four weeks prior to the study. The required information was obtained using self-administered questionnaires which were deposited at the selected nursery schools within Uyo metropolis.

The sample size for this study was calculated using the EpiInfo Stat Calculator for calculating frequency in a population with an estimated population (N) of 3,920,208 (26), 5% confidence limits and 26.2% prevalence of HCSB. (28) With these criteria the calculated sample size was 298 which was adjusted for 10% non-response to n = 328 (298 X 1.1 = 328).

The sample (328) was equally divided among the 10 selected schools and thus 33 questionnaires were given to each school. The questionnaires were distributed to the mothers through their proprietors/school administrators who contacted them using WhatsApp/emails. The forms were left for them to pick up and return at the school administrative office. Completed forms were crosschecked before being picked up from the schools after a sizable number were returned. Also, to ensure adequacy of sample size and in case of non-response, the questionnaire was created using Google Docs and an online survey link was placed on social media to further recruit eligible study participants.

Exposures and outcomes

The primary outcome variable for this study was healthcare-seeking behavior while the exposure variables were age (of caregiver and child), sex (child), marital status, ethnicity, level of education, occupation, family size, average monthly income, presence of fever, time to HCSB.

Definition of terms

In this study, fever was defined as hotness of the body of the under-five children assessed by the caregivers through touch anytime within the four weeks preceding the study. Appropriate healthcare-seeking behavior was defined as when care is first sought for the febrile child from a health facility i.e. hospitals, health centers, private clinics, or health posts within ≤ 24 hours of onset of fever.

Data analysis

Data analysis was conducted using the statistical program for social sciences (SPSS) version 16. Data was analysed using both descriptive and inferential statistics. Descriptive statistics included frequencies and percentages for categorical variables while measures of central tendency i.e. mean, median and measures of dispersion i.e. the standard deviation were calculated for numeric variables. Inferential statistics using bivariate analysis of the outlined variables and the presence or absence of appropriate healthcare-seeking behavior with unadjusted odds' ratios and 95% confidence intervals were calculated for each and a p-value of ≤ 0.05 was taken as statistically significant. Subsequently, those variables found to have a statistically significant association with healthcare-seeking behavior were further analysed to determine significant predictors of HCSB using a multivariate logistic regression analysis with adjusted odds' ratios and 95% confidence interval calculated for each variable.

Sociodemographic characteristics of caregivers

Three hundred and twenty-eight (328) mothers/caregivers of febrile under-five children were recruited into this study which is equal to the calculated sample size meaning a response rate of 100%. Their sociodemographic characteristics are as highlighted in Table 1. The modal age group is age 25–30 years, while the mean age of caregivers is 31.9 years with standard deviation of 5.7 years (Table 1). Table 1 also reveals that most caregivers were married (77.7%), Pentecostal Christians (62.2%) and of Ibibio ethnic nationality (61.6%), with tertiary education as the highest and most common educational attainment (39.9%).

Table 1

Sociodemographic characteristics of caregivers
Characteristics	Frequency (N = 328)	Percentage (%)
Age of Caregiver
< 25 years	41	12.5
26–30 years	107	32.6
31–35 years	93	28.4
36–40 years	63	19.2
> 40 years	24	7.3
Mean age in years (Standard deviation)	31.9(5.7)
Marital Status
Unmarried	47	14.3
Married	255	77.7
Divorced/Widowed	26	7.9
Religion
Orthodox	105	32.0
Pentecostal	204	62.2
Others	19	5.8
Ethnicity
Ibibio	202	61.6
Annang	41	12.5
Oro	27	8.2
Others	58	17.7
Educational Attainment
No formal Education	7	2.1
Primary	25	7.6
Secondary	127	38.7
Tertiary	131	39.9
Postgraduate	38	11.6
Occupation
Farmer	24	7.3
Govt Worker/Profession	66	20.1
Petty Trader/Artisan	69	21.0
Businesswoman	124	37.8
Housewife (Unemployed)	45	13.7

Table 1

Demographic Characteristics of children and household features in the study

Most children in the study were male (54.6%), aged between 24–35 months (27.7%) with mean age and standard deviation of 27.9 ± 14.6 months (Table 2). The median family size in the study was 5 persons ranging between 2 and 15 persons in a household (Table 2). Table 2 shows that about 2 in every 5 participants is from a family with an average income less than twenty thousand naira monthly (39.0%) and about two-thirds have only one under-five child in the household (32.6%). Slightly above a tenth of participants (12.2%) have an history of child death (Table 2).

Table 2

Demographic characteristics of children and households in the study
Characteristics	Frequency (N = 328)	Percentage (%)
Sex of Children
Male	179	54.6
Female	149	45.4
Age of children
< 12months	55	16.8
12–23 months	66	20.1
24–35 months	91	27.7
36–47 months	68	20.7
48–59 months	48	14.6
Mean age of children in months with SD	27.9	14.6
Family Size
≤ 3 Persons	79	24.1
4–6 Persons	215	65.5
> 7 Persons	34	10.4
Median family size with range	5(2–15)
Average Monthly Family Income
< N20,000	128	39.0
N20–50,000	108	32.9
N50 -100,000	62	18.9
> N100,000	30	9.1
Number of Under-5 Children in Household
1 Under-5 Child in household	221	67.4
> 2 Under-5 Children in household	107	32.6
Median Number of Under-5 children	1(1–5)
Household Setting
Urban	224	68.3
Rural	104	31.7
History of Child death in Household
Yes	40	12.2
No	288	87.8

Table 2

As presented in Table 3, most caregivers in the study diagnosed fever in their under-five children by touch (89.0%) and the most commonly associated clinical symptoms were cough and catarrh (71.3%) and vomiting and diarrhea (29%).

Table 3

Clinical Symptoms among children in the study
Characteristics	Frequency (N = 328)	Percentage (%)
How was Fever Diagnosed in child
By Touch	292	89.0
By Thermometer	36	11.0
Associated Clinical Symptoms
Cough and Catarrh	234	71.3
Vomiting and Diarrhoea	95	29.0
Others	6	1.8
None	55	16.8

Patterns of healthcare seeking behaviour among study participants

Only three-quarters of caregivers in the study sought healthcare from health facilities at any time (75.9%) for their under-five children with fever (Table 4). Most caregivers first visited the community pharmacy and/or patent medicine stores (35.1%) for the care of their under-five children with fever while only 22.3% first visited the health facility. In relation to reasons for visiting the health facility among caregivers who visited the facility (249), 70.3% reported that they visited the health facility to prevent the febrile condition from worsening and 23.7% visited because the child’s condition worsened. Only slightly above a tenth of the study population was categorized as having an appropriate healthcare seeking behaviour (12.5%) since they presented their febrile children in a health facility within the first 24 hours of the onset of symptoms (Table 4).

Table 4

Patterns of healthcare seeking behaviour among study participants
Characteristics	Frequency (N = 328)	Percentage (%)
Caregiver sought healthcare for child
Yes	249	75.9
No	79	24.1
First place to seek care
From Pharmacy and Patent Medicine stores	115	35.1
From Health Facility	73	22.3
From Family and Friends	50	15.2
From CAM¹	11	3.4
Sought No care	79	24.1
Reason for visiting health facility for care (n = 249)
To prevent worsening of illness	175	70.3
Worsening health condition	59	23.7
Others	10	4.0
Advice from family and friends	5	2.0
Did not seek care from Health facility	79	24.1
Time healthcare was sought in health facility
Within 24 hours	41	12.5
Day 2–3 of symptoms	117	35.7
Day 4–7 of symptoms	71	21.6
> 7days of symptoms	20	5.5
Never, did not seek care from Health facility	79	24.1
Appropriateness of HCSB
Inappropriate HCSB	287	87.5
Appropriate HCSB	41	12.5
¹CAM – Complementary and Alternative Medicine includes traditional healers, religious homes etc.

Table 4

Sociodemographic characteristics and Appropriate HCSB

Table 5 shows analysis of health care seeking behavior with sociodemographic characteristics and reveals that only the religion and the highest educational attainment of caregivers have a significant relationship with appropriate healthcare seeking behaviour. While 16.7% of caregivers with Christian Pentecostal religion reported appropriate healthcare seeking behavior only 6.7% of those with Christian Orthodox reported such behavior (X² = 9.22, p = 0.01). Similarly, 36.8% of those with postgraduate level of education exhibited appropriate HCSB while 0% of those with no formal education demonstrated appropriate HCSB (Χ² = 24.68, p = 0.00). The caregivers’ age, marital status, ethnicity, and occupation are not significantly related to appropriate HCSB in the study population (p > 0.05).

Table 5

Relationship between sociodemographic characteristics and Appropriate HCSB
Characteristics	Total	HCSB – Frequency (%)		X²/ Fishers’ test	p-value
		Appropriate	Inappropriate	X²/ Fishers’ test
Age group of Caregiver
≤ 25 years	41	2 (4.9)	39 (95.1)	6.40	0.171
26–30 years	107	12 (11.2)	95 (88.8)
31–35 years	93	15 (16.1)	78 (83.9)
36–40 years	63	11 (17.5)	52 (82.5)
> 40 years	24	1 (4.2)	23 (95.8)
Marital Status
Single	47	2 (4.3)	45 (95.7)	3.55	0.169
Married	255	39 (14.1)	219 (85.9)
Divorced/Widowed	26	3 (11.5)	23 (88.5)
Religion
Christian Orthodox	105	7 (6.7)	98 (93.3)	9.22	0.01*
Christian Pentecostal	204	34 (16.7)	170 (83.3)
Others	19	0 (0.0)	19 (100.0)
Ethnicity
Ibibio	202	28 (13.9)	174 (86.1)	2.62	0.453
Annang	41	4 (9.8)	37 (90.2)
Oro	27	1 (3.7)	26 (96.2)
Others	58	8 (13.8)	50 (86.2)
Educational Attainment
No formal Education	7	0 (0.0)	7 (100.0)	24.68	0.001*
Primary	25	3 (12.0)	22 (88.0)
Secondary	127	14 (11.0)	113 (89.0)
Tertiary	131	10 (7.6)	121 (92.4)
Postgraduate	38	14 (36.8)	24 (63.2)
Occupation
Farmer	24	1 (4.2)	23 (95.8)	5.22	0.266
Government Worker/Profession	66	8 (12.1)	58 (87.9)
Petty Trader/Artisan	69	8 (11.6)	61 (88.4)
Businesswoman	124	21 (16.9)	103 (83.1)
Housewife (Unemployed)	45	3 (6.7)	42 (93.3)

Table 5

Child and household characteristics and Appropriate HCSB

Table 6 shows analysis of healthcare seeking behavior with child and household characteristics and indicates that sex and age of the under-five child did not influence the healthcare seeking behaviour of the caregiver (p > 0.05). Table 6 also shows that increase in family size affects HCSB positively (X² = 8.23; p = 0.016). While only 3.8% of caregivers with 3 persons or less in their households demonstrated appropriate HCSB, as high as 20.6% of caregivers with greater than 6 persons in the household exhibited appropriate HCSB in the study. The same trend of increasing appropriate HCSB was noticed with increasing average monthly family income (X² = 9.77; p = 0.021).

Table 6

Relationship between demographic features of under-5 children, household characteristics and Appropriate HCSB
Characteristics	Total	HCSB – Frequency (%)		X²/ Fishers’ test	p-value
		Appropriate	Inappropriate	X²/ Fishers’ test
Sex of Children
Male	179	21 (11.7)	158 (88.3)	0.21	0.645
Female	149	20 (13.4)	129 (86.6)
Age of children
< 12months	55	9 (16.4)	46 (83.6)	6.77	0.149
12–23 months	66	13 (19.7)	53 (80.3)
24–35 months	91	8 (8.8)	83 (91.2)
36–47 months	68	8 (11.8)	60 (88.2)
48–59 months	48	3 (6.3)	45 (93.8)
Family Size
≤ 3 Persons	79	3 (3.8)	76 (96.2)	8.23	0.016*
4–6 Persons	215	31 (14.4)	184 (85.6)
> 6 Persons	34	7 (20.6)	27 (79.4)
Average Monthly Family Income
< N20,000	128	8 (6.3)	120 (93.8)	9.77	0.021*
N20–50,000	108	20 (18.5)	88 (81.5)
N51 -100,000	62	7 (11.3)	55 (88.7)
> N100,000	30	6 (20.0)	24 (80.0)
Number of Under-5 Children in Household
1 Under-5 Child in household	221	29 (13.1)	192 (86.9)	0.24	0.624
> 2 Under-5 Child in household	107	12 (11.2)	95 (88.8)
Household Setting
Urban	224	27 (12.1)	197 (87.9)	0.13	0.720
Rural	104	14 (13.5)	90 (86.5)
History of Child death in Household
Yes	40	4 (10.0)	36 (90.0)	0.26	0.610
No	288	37 (12.8)	251 (87.2)

Table 6

Clinical symptoms of under-5 children and Appropriate HCSB

Diagnosing fever using a thermometer had a significant relationship with appropriate HCSB (X² = 5.78; p – 0.016). Other associated clinical symptoms showed no statistically significant relationship with HCSB (Table 7).

Features of the health condition and Appropriate HCSB

Table 7 shows analysis of healthcare seeking behavior with the characteristics of the health condition. While the reasons for seeking healthcare for the under-five children (X² = 15.44; p – 0.001) showed a significant relationship with appropriate HCSB, the first place the caregivers sought healthcare was not significantly related to HCSB (X² = 6.26; p – 0.099). More caregivers who sought healthcare to prevent worsening of the child’s clinical condition had appropriate HCSB than caregivers who gave other reasons for seeking care (Table 7).

Table 7

Relationship between Clinical symptoms of under-5 children, health seeking features and Appropriate HCSB
Characteristics	Total	HCSB – Frequency (%)		X²/ Fishers’ test	p-value
		Appropriate	Inappropriate	X²/ Fishers’ test
Diagnosis of Fever
Touch	292	32 (11.0)	260 (89.0)	5.78	0.016*
Thermometer	36	9 (25.0)	27 (75.0)
Other associated clinical Symptoms
No other symptoms	55	10 (18.2)	45 (81.8)	7.46	0.114
Cough and catarrh	172	20 (11.6)	152 (88.4)
Diarrhoea and vomiting	33	7 (21.2)	26 (78.8)
All 4 Symptoms	62	3 (4.8)	59 (95.2)
Others	6	1 (16.7)	5 (83.3)
First place to seek care
Health Facility	73	16 (21.9)	57 (78.1)	6.26	0.099
Family and Friends	50	3 (6.0)	47 (94.0)
Pharmacy and Patent Medicine stores	115	21 (18.3)	94 (81.7
From CAM¹	11	1 (9.1)	10 (90.9)
Reason for visiting health facility for care
Worsening health condition	59	1 (1.7)	58 (98.3)	15.44	0.001*
To prevent worsening of condition	175	39 (22.3)	136 (77.7)
Advice from family and friends	6	1 (0.0)	5 (100.0)
Others	9	0 (0.0)	9 (100.0)

Predictors of Appropriate HCSB among caregivers of under-5 children.

Table 8 shows the results of bivariate and multivariate logistic regression analysis for variables which were shown to be significantly associated with appropriate HCSB which are religion, education, family size, family income, method of fever diagnosis, and reason for the visit.

In the multivariate regression analysis, which gives the adjusted odds ratio and shows the relationships between significant variables, the method of diagnosing fever was no longer significant (p > 0.05). Religion, highest educational attainment, family size, average monthly family income and the reason caregivers sought healthcare remained significant predictors of appropriate HCSB in the multivariate logistic regression (Table 8). Caregivers who are Pentecostal were significantly more likely to seek healthcare within the first 24 hours compared to the Orthodox (aOR 3.53, 95% CI 1.32–9.44, p = 0.01). In terms of educational attainment, those with educational levels lower than postgraduate were less likely to exhibit appropriate HCSB (aOR 0.18, 95% CI 0.06–0.55, p = 0.00). In contrast, those with family size ≥ 7 persons were more likely to seek appropriate healthcare compared to those with family size < = 3 persons (aOR 7.02, 95% CI 1.36–36.35, p = 0.02). For average monthly income, those who earned above N20,000 were more likely to exhibit appropriate HCSB (aOR 3.43, 95% CI 1.15–10.27, p = 0.02). Among the reasons proffered for visiting the health facility, those who said that they wanted to prevent the condition from worsening were eleven times more likely to seek appropriate healthcare (aOR 11.72, 95% CI 1.44–95.29, p = 0.02).

Table 8

Predictors of Appropriate HCSB among caregivers of under-5 children.
Variables	Bivariate Regression			Multivariate Regression
Variables	UOR	95% CI	P	aOR	95% CI	P
Religion
Orthodox	1	-	-	1	-	-
Pentecostal	2.80	1.19, 6.55	0.018*	3.53	1.32, 9.44	0.012*
Others	0.12	0.01, 17.01	0.121	0.19	0.01, 19.10	0.181
Educational Attainment
No formal Education	0.26	0.01, 19.02	0.153	0.99	0.01, 18.72	0.923
Primary	0.23	0.06, 0.92	0.038*	0.90	0.15, 5.29	0.911
Secondary	0.21	0.09, 0.50	0.001*	0.42	0.14, 1.30	0.134
Tertiary	0.14	0.06, 0.36	0.001*	0.18	0.06, 0.55	0.002*
Postgraduate	1	-	-	1	-	-
Family Size
≤ 3 Persons	1	-	-	1	-	-
4–6 Persons	4.268	1.27, 14.38	0.019*	3.030	0.81, 11.40	0.101
≥ 7 Persons	6.568	1.58, 27.23	0.009*	7.026	1.36, 36.35	0.020*
Average Monthly Family Income
< N20,000	1	-	-	1	-	-
N20–50,000	3.409	1.44, 8.09	0.005*	3.438	1.15, 10.27	0.027*
N50 -100,000	1.909	0.66, 5.53	0.233	3.109	0.74,13.04	0.121
> N100,000	3.750	1.19, 11.79	0.024*	1.729	0.37, 8.02	0.484
Diagnosis of Fever
Touch	1	-	-	1	-	-
Thermometer	2.71	1.17, 6.28	0.020*	0.95	0.33, 2.68	0.916
Reason for visiting health facility for care
Worsening health condition	1	-	-	1	-	-
To prevent worsening of condition	16.63	2.23, 123.95	0.006*	11.72	1.44, 95.29	0.021*
Advice from family and friends	11.60	0.50, 22.15	0.128	6.44	0.89, 18.01	0.226
Others	0.67	0.04, 10.99	0.782	0.41	0.02, 7.04	0.537

Table 8

The healthcare seeking behavior (HCSB) of mothers/caregivers of under five children is an important determinant of morbidity and mortality in this age group as they are primarily dependent on their caregivers for access to care. Numerous factors interact to bring about the manifestation of HCSB that is observed in these caregivers.

In this study, although over 75% of mothers sought one form of care or the other for their febrile children, only 12.5% exhibited appropriate HCSB i.e. attended a health facility within the first 24 hours of the onset of symptoms. This percentage of appropriate HCSB is abysmally low when compared to findings by Oluchi et al 18.6%, Abegaz 26.5%, Simieneh 27% and Lovelyn 30.2%. (17, 25, 29, 30) This value is also grossly below the national average for the country of 31.4%. (31) Other researchers have obtained higher figures ranging between 40–57.0%. (16, 19, 32) This variation could be explained by differences in sample population and methodology. Also, it is probable that due to the lockdown period as a result of the Covid 19 pandemic, there was restriction of movement and thus, many mothers might have been forced to seek for care at nearby pharmacies and patent medicine stores.

Another possible reason adduced for the very low percentage of appropriate HCSB in this study was supported by the finding that above a third (35.0%) of the study population visited the local pharmacies/patent medicine stores first instead of going to a healthcare facility and most caregivers only resorted to visiting the healthcare facilities either because the child’s symptoms worsened or to prevent the symptoms from worsening. This trend towards accessing care from local pharmacies was also noted by Abegaz where 24.5% of the caregivers in their study went first to the pharmacy for healthcare services for their children. (29)

The method used by mothers to ascertain the presence or absence of fever and its severity in their wards also influenced their decision to seek healthcare from appropriate quarters. In this study, almost 90% of mothers ascertained the presence of fever using touch. Various researchers have documented the fact that although the sensitivity and specificity of using touch as a means of assessing fever is subjective, it should not be disregarded. (11, 12, 33, 34) This subjective assessment of fever may have accounted for the poor HCSB noticed among caregivers who assessed fever by touch. However, the study demonstrated that a higher proportion of caregivers who used thermometer to assess fever in their wards were found to display appropriate HCSB. This maybe because the use of a thermometer is a more objective way of assessing fever and paints a better picture of the severity of the fever, hence the caregiver is motivated early to seek care in a healthcare facility to forestall complications or worsening of the condition.

Several factors were found to be significant predictors of appropriate healthcare seeking behaviour in this study and these were educational attainment, average monthly family income, perception of the severity of illness by the caregivers i.e. reasons why the mothers sought care, and family size and religion.

Level of educational attainment was a significant predictor of appropriate HCSB in this study. The higher the level of education, the more likely caregivers were to take their children to the healthcare facility promptly. This finding is corroborated by several researchers. (17, 19, 21, 35) Indeed, Abegaz et al found that mothers with secondary level of education were four times more likely to seek healthcare when compared with those with primary education or no formal education. (29) Education exposes the caregiver to appropriate childcare practices which leads to a better appreciation of clinical symptoms in children. The Educated caregivers are also more likely to know the healthcare facilities to take a child when ill; more financially empowered and better equipped to transport the child to the healthcare facilities.

Average monthly family income was another significant factor affecting appropriate HCSB in this study population. This finding is corroborated by some researchers. (16, 17, 21, 36) Those who earned between N20,000-N50,000 were three and a half times more likely to seek appropriate healthcare compared to those earning below N20,000. This significance appears to be lost in those earning above N50,000. The likely explanation for this apparent contradiction may be that in the category of those earning N50,000-N100,000, there were too few people (seven) to be able to satisfactorily assess the level of significance of the results obtained. However, higher family income enables caregivers to pay for transportation to the health facility and also access drugs and other treatment in a country where healthcare is paid for from out of pocket expenditure.

The caregivers’ perception of the severity of illness in their wards was also a significant predictor of HCSB. This was assessed by the reasons that were proffered by them for seeking appropriate healthcare which was to prevent the disease condition from worsening. Kolola et al in their study noted that caregivers who perceived that the child’s illness was severe were three times more likely to take the child to a healthcare facility on time. (18) This is also in keeping with findings by other researchers. (16, 29, 30) Indeed, a mothers’ knowledge of danger signs in an ill child has been found to be associated with better HCSB like it was demonstrated in this study. (37) Caregivers who wanted to prevent the worsening of clinical symptom were eleven times more likely to have appropriate HCSB, than caregivers who could not recognize clinical symptoms until it got worse at home.

In the index study, family size was a significant determinant of HCSB and demonstrated a direct relationship with appropriate HCSB i.e. the larger the family size, the more likely it was that a caregiver would promptly take the child to a health facility. This was a surprising finding as most researchers have shown either no association (18, 21) or an inverse relationship between family size and HCSB. (25) Possible reasons for this behaviour may be that larger families have more people available to take care of other children in the household while freeing the mother to seek healthcare for the affected child however, this relationship needs to be further investigated.

Another unexpected finding in this study was the positive relationship between appropriate HCSB and mothers/caregivers who belonged to the Pentecostal religious denomination. They were three and a half times more likely to seek timely care for their children at a health facility. This was contrary to findings by Bedford and Sharkey were some Pentecostal denominations were averse to the use of medical treatment by their adherents due to their emphasis on faith healing. (38) This finding may point to the possibility of more exposure to health education messages in this denomination compared to others as many of the adherents also have high educational status. Thus, religious, and sociocultural factors also play a significant role in the HCSB of caregivers as seen in this study.

Factors such as maternal age, marital status, occupation, gender and age of the affected child, residence and experience of child death were not found to be significant predictors of appropriate HCSB in this study. This is in consonance with the findings by some researchers(18, 21) but at variance with the findings by several others. (30, 35) A larger study with a larger sample size may perhaps bring better clarification of the influence of these factors on HCSB than has been seen in the present study.

The following study limitations were noted: the study was based on the caregivers’ perception of illness in the children which in over 80% of cases was based on a subjective assessment of fever which was not validated by healthcare personnel. Also, the ability of the caregivers to recall accurately the treatment seeking procedure which took place over four weeks and other facts of the illness makes the study subject to recall bias. Another source of bias in this study was selection bias in which only mothers who had children enrolled in school and those who could understand and speak English were part of the study. This affected the representativeness of the study population. Another limitation was the inability to conduct full face to face interviews which would have helped to fully elucidate underlying belief systems (the study was conducted during the Covid 19 lockdown).

In conclusion, the percentage of appropriate healthcare seeking behaviour by mothers/caregivers of febrile under five children was low (12.5%). Significant predictors of appropriate healthcare seeking behaviour in these mothers/caregivers were higher level of educational attainment, perceived illness severity, higher average monthly household income and bigger family size. The percentage of appropriate HCSB was found to be abysmally low. It is lower than the regional and national percentages. This has implications for public health service, practice, and delivery. Prompt healthcare seeking behaviour of mothers/caregivers of children plays a major role in reducing the morbidity and mortality that is associated with childhood illness and by extension the under-five mortality rate. The under-five mortality rate for Akwa Ibom state is the highest in the south-south region Thus, urgent steps need to be taken at the community and state levels to remediate the situation and to prevent avoidable child deaths. The overall implications of the findings of this study are that social determinants of health play a very significant role in HCSB of mothers in our environment and directly or indirectly affects their ability to access health services with the resultant increase in under-five morbidity and mortality.

U5MR

Under 5 mortality rate

HCSB

Healthcare seeking behaviour

Ethics approval and consent to participate

Ethical clearance for the study was obtained from the University of Uyo Teaching Hospital health research and ethics committee (UUTH/AD/S/96/VOL.XXI/438). Informed, written consent was obtained from the survey participants who were required to append their signatures to the consent form. For those participating in the survey online, it was clearly stated that agreement to participate in completing the online survey would be regarded as consent. The survey was anonymous with the non-inclusion of personal identifiers on the questionnaires. Also, the data obtained was stored in a pass-worded computer while the questionnaires were stored in locked file cabinets with access restricted to only the principal researcher.

Consent for publication: Not applicable

Availability of data and materials: All data generated or analysed during this study are included in this published article [and its supplementary information files].

Competing interests: The author declares that she has no competing interests.

Funding: Research solely funded by author

Authors' contributions: Research was solely conceptualized and executed by the author

Acknowledgements: I would like to acknowledge the invaluable contributions of Dr Nasih Othman and Prof Chika Duru to this work.

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No competing interests reported.

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Healthcare Seeking Behavior of Mothers of Under-five Children With Febrile Illness and Associated Factors in Uyo Metropolis

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Abstract

Background

Methods

Results

Conclusion

Background

Methods

Sampling and recruitment of participants/data collection

Exposures and outcomes

Definition of terms

Data analysis

Results

Sociodemographic characteristics of caregivers

Demographic Characteristics of children and household features in the study

Patterns of healthcare seeking behaviour among study participants

Sociodemographic characteristics and Appropriate HCSB

Child and household characteristics and Appropriate HCSB

Clinical symptoms of under-5 children and Appropriate HCSB

Features of the health condition and Appropriate HCSB

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

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