Pneumonia Knowledge and Care Seeking Behavior for Children Under-five Years in Jigawa, Northwest Nigeria: A Cross-sectional Study

"[F]indings suggest that care seeking for children under-five in this setting may be driven by lived experiences and community norms about childhood illness; hence, community-based interventions aimed at improving care seeking must not focus only on improving caregiver's knowledge but address wider contextual factors."

Research shows that interventions to improve care-seeking practices for children and reduce under-five mortality must address contextual factors such as social and gender norms, inequity, and economic and health-system-related factors. This study sought to describe caregiver knowledge and care-seeking behaviour for childhood pneumonia, in a high child mortality setting in Nigeria, to inform the development of effective community-based interventions for pneumonia control.

Between December 2019 and March 2020, the researchers conducted a cross-sectional household survey in Kiyawa local government area (LGA), Jigawa State, Nigeria, as part of the baseline phase of the INSPIRING Jigawa community-based cluster randomised controlled trial (RCT). The researchers asked 1,661 mothers of a total of 2,828 children under age 5 about their knowledge of pneumonia symptoms, prevention, risks, and treatment. They showed them videos of pneumonia specific symptoms and asked (1) if their child had any respiratory symptoms in the 2-weeks prior; (2) their subsequent care-seeking behaviour. Multivariate regressions explored socio-demographic and clinical factors associated with care seeking.

Only 4.9% of women could name both cough and difficulty/fast breathing as pneumonia symptoms, and the composite knowledge scores for pneumonia prevention, risks, and treatment were low. Overall, 19.0% (536/2828) of children had a report of pneumonia-specific symptoms in the prior two weeks, and, of these, 32.3% (176/536) were taken for care. Possible explanations of this failure to seek care could be that the symptoms were perceived as not serious, or the normative care-seeking practices in the setting do not include seeking care outside home. The odds of care seeking were higher among children: with fever (adjusted odds ratio (AOR):2:45 [95% confidence interval (CI): 1.38-4.34]); from wealthiest homes (AOR: 2:13 [95% CI: 1.03-4.38]), and whose mother first married at 20-26 years compared to 15-19 years (AOR: 5.15 [95% CI: 1.38-19.26]).

Notably, the caregiver's knowledge of pneumonia was not associated with care seeking. Less than 5% of women knew that being close to someone sick or coughing are risk factors. Addressing misinformation and gaps in knowledge about pneumonia "risks requires urgent attention to increase community awareness about the burden of pneumonia. This may help to reduce pneumonia incidence because caregivers will become empowered to take appropriate steps to prevent childhood pneumonia." Furthermore, considering that more than two-thirds of children with no pneumonia symptoms were prescribed antibiotics, campaigns against antibiotics misuse need to include lower-level providers and incorporate community engagement.

Women with previous child loss delayed care seeking for their children. This finding may suggest lack of trust in healthcare based on previous negative outcomes, but it may also highlight persisting barriers such as socio-cultural issues, geographical access to quality health services, and health literacy. It will be important to explore the barriers faced in accessing care for this group of caregivers.

In conclusion: "Care seeking for children under-five who had ARI symptoms was not associated with caregiver's knowledge of the disease. Lived experiences and community perceptions of childhood illnesses may play a more important role in this setting. Therefore, when designing public health interventions to address child mortality, information-giving alone, is likely to be insufficient. Instead working to challenge pervasive misconceptions and social norms will be needed to ensure that practical barriers to care are minimized."

Full list of authors, with institutional affiliations: Ayobami A. Bakare, Karolinska Institute and University College Hospital; Carina King, Karolinska Institute; Julius Salako, University of Ibadan; Damola Bakare, University of Ibadan; Obioma C. Uchendu, University College Hospital and University of Ibadan; Rochelle Ann Burgess, University College Hospital; Funmilayo Shittu, University of Ibadan; Agnese Iuliano, University College Hospital; Adamu Isah, Save the Children International; Tahlil Ahmed, Save the Children UK; Samy Ahmar, Save the Children UK; Paula Valentine, Save the Children UK; Temitayo Folorunso Olowookere, GlaxoSmithKline (GSK); Eric D. McCollum, Johns Hopkins University; Tim Colbourn, University College Hospital; Adegoke G. Falade, University of Ibadan and University College Hospital; Hamish R. Graham, University College Hospital and University of Melbourne - on behalf of the INSPIRING Project Consortium