Mothers knowledge of danger signs in childhood illnesses: the integrated management of childhood illness (IMCI) strategy in Alimosho area of Lagos State, Nigeria

Mothers knowledge of danger signs in childhood illnesses: the integrated management of childhood illness (IMCI) strategy in Alimosho area of Lagos State, Nigeria

Edem Samuel Duke^1,2, Beatrice Nkolika Ezenwa^3,&, Alero Roberts², Ekanem Efiong Ekanem²

¹Department of Pediatrics, Alimosho General Hospital Igondo, Lagos, Nigeria, ²Department of Community Health and Primary Care, University of Lagos, Lagos, Nigeria, ³Department of Paediatrics, College of Medicine University of Lagos, Lagos, Nigeria

^&Corresponding author
Beatrice Nkolika Ezenwa, Department of Pediatrics, College of Medicine University of Lagos, Lagos, Nigeria

Introduction    

Every year, more than 10 million children under five years die [1] due to preventable causes. In Lagos state alone, one out of every 20 live births die before reaching their fifth birthday [2]. The World Health Organization (WHO) and the UNICEF (United Nation International Children Emergency Fund) recognizing the importance of care seeking, enumerated activities to improve family and country health practices such as danger signs recognition and care seeking as part of the central components of the integrated management of childhood illness(IMCI) [3,4]. Adequate knowledge and recognition of danger signs is a vital parenting tool with resultant positive impact on the health care seeking behavior [5,6]. Families need to respond appropriately when their children are ill, seek appropriate care and timely assistance and offer recommended treatment [6,7]. According to the community integrated management of childhood illness strategy, mothers/caregivers at home should have adequate knowledge of the causes, prevention as well as when to seek appropriate help in the health facility when a child is not getting better [8]. Danger signs are warning signs indicating potential hazardous conditions that may become life threatening. Danger signs in IMCI include a child being excessively thirsty or unable to drink, (or breastfeed), vomiting everything given, convulsing during current illness, the child being lethargic, no longer smiling, talking, crying, walking or becoming unconscious [1,9]. Other danger signs are difficult breathing or fast breathing and high-grade fever [10]. The ability of the caregiver or mother to recognize these danger signs and know when to seek help will reduce morbidity and mortality from the underlying cause. A mother´s knowledge and recognition of critical signs and symptoms is important in determining the outcome of a child´s ill health.

Studies done in health facilities from low and middle-income countries showed that mothers´ knowledge of certain signs and symptoms of childhood illnesses and perceived illness severity, were important factors determining health-seeking behaviors [11-13]. Delay in seeking appropriate care or not seeking any care at all, contribute immensely to deaths in children [13]. Mothers are the primary caregivers for their children. Their ability to recognize the severity of illness early enough will determine their responses in preventing mortality by seeking early treatment. There is the need to ensure that mothers know danger signs of various illnesses especially when they are life threatening. Signs like difficulty in breathing, lethargy, convulsions, excessive vomiting refusal to drink and fever are signs that mothers ought to be familiar with. There is limited data on danger signs knowledge in community-based studies in Nigeria. This community-based study therefore, aimed to collect baseline information on mothers regarding the knowledge of danger signs of common childhood illnesses and to assessed their health-seeking behaviors in under-five children in Alimosho local government area of Lagos State. The information gathered should aid policy makers in setting up strategies that will further decrease the mortality rate due to childhood illnesses in the local government.

Methods     

This was a community-based descriptive cross-sectional study conducted on mothers with children under-five years of age who reside in Alimosho LGA, a semirural area of Lagos State. Mothers were excluded if they were visitors in Alimosho, did not have an under-5 child during the study period or declined consent to participate in the study. Caregivers who were not direct mothers of the under-5 children were also excluded. A minimum sample size of 360 participants was calculated using the Cochran formula for cross-sectional studies while assuming a 10% non-response rate. A multistage sampling technique was employed to select the 360 participants for the study. Using the lists of wards in Alimosho Local Government area as a sampling frame, six wards were selected from the sample frame of 36 wards using simple random sampling method. From lists of the streets obtained from the LGA council, 6 streets from each ward were selected by balloting. There was an average of 30 houses per street. Ten of the 30 houses on each street were selected by systematic sampling, every third house was selected. The starting point was identified by balloting. One household was selected by balloting if there were more than one household per house. An eligible mother with a child below five years was selected for questionnaire administration. In a household where there was more than one eligible participant, one was selected by balloting. Where the mother in the selected household was unavailable or declined consent, the next house was selected and the questionnaire administered until the required 360 was achieved.

Data collection: data was obtained using an interviewer administered, standardized and structured questionnaires which was adapted from the IMCI questionnaire [9,14]. The questionnaires had four sections: Socio-demographic characteristic, mother´s knowledge of danger signs, their attitude and health seeking behavior during a child´s illness. Mother´s knowledge of danger signs were sought for in fever, cough, diarrhoea, fast breathing with chest in-drawing, difficulty in breathing, restlessness, drowsiness, weakness, inability to play, convulsions in current illness and loss of consciousness. To assess knowledge, each question on danger signs answered correctly was given a score of one, while questions answered wrongly were awarded a score of zero. The scoring was then converted to percentage. A score of >75% was scored as good or adequate knowledge, while a score of ≤74%, was scored as poor knowledge. A five point Likert scoring system (strongly agreed, agreed, not sure, disagreed, strongly disagreed) was used to categorize the perception and attitude of mothers towards childhood illness and danger signs while the health seeking behavior of mothers for a child with danger signs were sought using questions that included if the child had ever been taken to any health facility.

Date analysis: data collected were coded, entered, cleaned, and analyzed using the statistical package for social science (SPSS) version 20.0. Results were presented in the form of tables and figures. Categorical data were presented using frequency and percentages while measures of central tendencies (mean and standard deviation; median and inter-quartile range) were used for continuous data where appropriate. Tests of association between dependent variables such as knowledge, attitude and health seeking behaviours were analyzed against the independent variables using Pearson chi-squared test or Fisher exact when the sample was small. A p- value <0.05 was regarded as statistically significant. Unconditional logistic regression analysis was used to examine determinants of knowledge, attitude and behavior while controlling for possible confounders. For this approach, knowledge, attitude and behvaiour were treated as dichotomous variables and recoded as 1 or 0 for adequate and poor respectively.

Ethical consideration ethical approval to conduct the study was obtained from the Human Research and Ethics Committee (HREC) of the Lagos University Teaching Hospital, Lagos and permission to conduct the study was also obtained from the chairman of Alimosho local Government Area, before commencement of the study. Informed consent was obtained from all the participants before administering the questionnaire. Anonimization of data collected was used to ensure confidentiality.

Results     

The 360 participants completely filled and returned the questionnaires. Table 1 shows the socio- demographic characteristic of the study participants. The mean maternal age was 32.69 ± 6.46 years. Majority of the respondents (81.4%) had between 2 and 4 children, while only 15.8% of mothers had 1 child. On the respondent´s knowledge and ability to recognize danger signs of childhood illnesses, nearly all the respondents were able to adequately recognize the general danger signs of illness in a child such as: fever (98.1% of the respondents), vomiting everything given (95 % of the respondents), child not feeding or breast feeding (94%), child unconscious (95.3 %), child convulsing (91.7% of the respondents). But only a little over two-thirds of the respondents were able to identify chest in-drawing as a critical danger sign in an ill child (78.6% of the respondents). Most of the mothers (77.2%) obtained information on danger signs of childhood illnesses from health workers while in 4.7% of the respondents, the source of information was from family members (Figure 1). Overall, 328 (91.1%) had good knowledge of danger signs of childhood illnesses, while 8.9% of the respondents had poor knowledge of the danger signs of childhood illnesses. When asked the prevalent danger signs the mothers encountered in the preceding two weeks before the study, fever had the highest prevalence (35% of the respondents) while convulsion was the least prevalent danger sign reported (16.7% of the respondents). Fast breathing and diarrhea recorded 29.2% and 20.0% responses respectively.

Table 2 shows mothers´ attitude towards danger signs of childhood illnesses. Most mothers agreed that they should worry when their child´s body is hot and that a child who is breathing fast is ill. They also agreed that a child who was passing watery stool should be placed on oral rehydration solution. Table 3 shows that there was a significant association between respondents´ level of knowledge and their educational status, as well as their parity (p < 0.05). Mothers´ with higher educational level had better knowledge and with increased parity comes experience and better knowledge. There was also a statistically significant association between respondents´ level of knowledge and their attitude level. Out of the 328 respondents classified as having good knowledge, 190 (58%) of them demonstrated positive attitude compared to the 32 with poor knowledge with 5 (15.6%) demonstrating positive attitude (p <0.001). Respondents with better knowledge of danger signs had more positive attitude towards childhood illnesses. Respondents who had good knowledge of danger signs also had better health seeking behavior and this was statistically significant, p = 0.001. Table 4 shows the relationship between maternal characteristics and appropriate IMCI practices. The maternal age was a significant determinant of appropriate practices. The older mothers were on the average more likely to engage in appropriate IMCI practices than the younger counterparts with a 5% increase in odds of better practice. When controlled for mothers age, parity was no longer significant at 0.05.

Discussion     

The likelihood for appropriate response to childhood illnesses increases with increased knowledge. This study assessed mothers´ knowledge of danger signs of common childhood illnesses in the context of IMCI and explored their attitudes and responses to these danger signs. A mother´s actions and inactions have been thought to influence children´s progression to illness or health and the ability of the mother to recognize a sick child has been associated with good response in terms of appropriate action [15]. This study, showed that knowledge of symptoms of childhood diseases was high in the respondents which is similar to the reports of other researchers [15-18]. In two studies conducted in Enugu, South East Nigeria, both reported high knowledge of danger signs in childhood illnesses among the respondents [16,17]. The studies from Tanzania [18] and Dar Salaam [19] also reported high awareness of danger signs recognition in respondents. In the present study, fever was the most critical and most prevalent danger sign reported in childhood illnesses while convulsion is the least prevalent. Fever was also documented in several studies as a major symptom in childhood illnesses [20-22]. The experience of the mother also improves danger signs recognition. Our study showed significant increase in the knowledge of the mothers about danger signs with increasing number of children they have. Increased parity comes with experience and better knowledge. This may be the reason Roberts et al reported that the ability to recognize danger signs was increased with maternal age and skill level [9]. Mothers´ with higher educational level also had better knowledge of danger signs. This may have come from exposure to different sources of information. Majority of the mothers reported their sources of information on danger signs to be from health care providers. Social media such as television and newspapers also contributed as sources of information for the respondents. Health information to the community on common childhood illnesses is the mandate of IMCI. The information provided by health care workers should be correct and devoid of ambiguities as the community depends on them for guidance.

The overall attitude of mothers towards the danger signs of childhood illnesses was positive and encouraging. The respondents´ knowledge and attitude to danger signs like fever, difficulty in breathing and fast breathing were high and they sought appropriate care for most of the childhood illnesses which is similar to the findings of Farhad et al. [23] and in keeping with the health belief model which states that if symptoms are perceived as a threat (danger signs), individuals take action [24]. The likelihood for appropriate response to childhood illnesses increased with increased knowledge. The practices reported by mothers to the danger signs were varied with respondents who had good knowledge of danger signs showing better practices with higher health seeking behaviors. The majority of the respondents in our study would take their children to health facilities if they have danger signs. This is similar to the study in Enugu [18], in which majority of the respondents also took their children to the hospitals when they had cough, rapid breathing or difficulty in breathing [16]. Our study however, showed poor health seeking behaviors in mothers with poor knowledge of danger signs. This is not unexpected as inability to recognize a danger may delay taking actions to mitigate it. Several studies had shown that perceived illness severity and maternal knowledge of certain signs and symptoms of childhood illnesses were important factors determining health-seeking behavior [12,23,25]. There is need to continue health education for mothers at every opportunity. IMCI should not relent as there is still a lot of work to be done. Health workers should be trained on how to pass effective information on practices concerning danger signs. This is the time to build on the progress being made on the sustainable development goals (SDGs). To meet up with the SDGs, more awareness should be created towards the danger signs of common childhood illnesses and the actions to mitigate it. The health of our children are priority and mothers had to be empowered to recognize dangers signs during illnesses and to take appropriate actions to ameliorate them.

Conclusion     

The knowledge of danger signs of common childhood illnesses by mothers in this study was high. A good number of them had positive attitude towards the identified danger signs with appropriate practices directed towards management of the childhood illnesses. However, a lot still need to be done to achieve the IMCI target and SDG goal three. Health care providers should consistently provide health education to mothers on danger signs of common childhood illnesses and employ the IMCI strategy in their management.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

ED developed the concept and design of the study, participated in the acquisition of data, drafted the manuscript and approved the final version to be published; BE contributed to the study design, interpretation of data, revised the manuscript for intellectual content and approved the final version to be published; AR contributed to the study design and revised the manuscript for intellectual content and approved the final version to be published; EE contributed to the study design, interpretation of data, revised the manuscript and approved the final version to be published.

Tables and figure     

Table 1: socio demographic characteristics of the study participants

Table 2: respondents' attitude and perceptions towards certain childhood illnesses and danger signs

Table 3: association between respondents' social demographic characteristics, health seeking behavior and level of knowledge of danger signs among the respondents

Table 4: unconditional logistic regression analysis of the relationship between maternal characteristics and appropriate IMCI practices

Figure 1: respondents' sources of information on danger signs

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