CAREGIVERS’ KNOWLEDGE, ATTITUDE AND
ISSELE-AZAGBA, DELTA STATE
OF NIGERIA IN PART FULFILMENT OF THE
REQUIREMENTS FOR THE AWARD OF THE FELLOWSHIP
OF THE MEDICAL COLLEGE IN PUBLIC HEALTH
(F.M.C.P.H)
2
DECLARATION
I declare that this dissertation titled “EFFECT OF HEALTH EDUCATION ON
CAREGIVERS’ KNOWLEDGE, ATTITUDE AND PRACTICE OF HOME-
MANAGEMENT OF ACUTE RESPIRATORY INFECTIONS IN UNDER-FIVES IN
ISSELE-AZAGBA, DELTA STATE” is my original and individual work.
It was done under the supervision of:
Dr K.A. ODEYEMI (FMCPH).
I also declare that this dissertation has not been submitted anywhere else in part or in full for
any other examination.
Lagos University Teaching Hospital, Lagos.
3
CERTIFICATION
I hereby certify that this study was carried out by Dr. Tosin Awele Idaboh, and the
dissertation was written by her under my direct supervision in the Department of Community
Health of the Lagos University Teaching Hospital, Idi-Araba, Lagos State.
To the best of my knowledge, the contents of this study have not been submitted to any other
examination board or for publication in any journal.
Supervisor:
Department of Community Health and Primary Care
Lagos University Teaching Hospital
Head of Department of Community Health and Primary Care
Lagos University Teaching Hospital
4
DEDICATION
To God almighty, the giver of life, wisdom and knowledge. Thank you Lord for keeping all
your promises!
To the memory of my dad, Dr. Gbaduabi Olufemi Atalabi who was a medical doctor himself
and insisted I studied medicine.
To the memory of my dear mum, Mrs. Ada Florence Atalabi who taught me to always fight
for the underprivileged in our society by standing up for them whenever I can. Mum, this is
for you!
To the memory of the children who have lost their lives from Acute Respiratory Infections
and other preventable childhood diseases. May their souls rest in peace!
It is my hope that this book will play a role or two in making a difference!
5
ACKNOWLEDGEMENT
My immense gratitude and appreciation goes to my supervisor, Dr Kofo Odeyemi for her
thorough supervision, encouragement and support throughout the residency programme and
specifically for this study. Thank you so much Ma, for your patience, guidance,
understanding and time, I could not have asked for a better supervisor and mentor.
My appreciation also goes to Prof Akin Osibogun for allowing me the privileged opportunity
to undertake this programme. Thank you Sir.
I also want to thank my uncle Prof. C.U Odum specially, for his unbridled support without
which this entire journey may have been a different story. Odua Uncle!
To my Oga, Dr. Bayo Onajole, for always taking out time to listen to my challenges and
solving them promptly. Thank you so much Sir for giving me the opportunity to serve as the
Chief Registrar of the Department of Community Health (LUTH) for as long as I did and
believing in me. Thank you Sir for the support and encouragement, I really appreciate
everything.
My profound gratitude goes to my wonderful teachers, Dr. B.E Ogunnowo, Dr. Olufunlayo,
Dr. Ebuehi, Dr. Victor Inem, Dr. Campbell, Dr. Roberts and all the other members of
academic staff. Dr Balogun, Dr. Okafor, Dr.Oridota, Dr. Sekoni, Dr.Olatona, Dr. Onigbogi,
Dr. Abiola. I thank you all so much for your words of encouragement, help and contributions
during various stages of this study.
6
I wish to appreciate Dr. Kemi Odukoya (my ‘mini supervisor’) for taking out time to help
edit this book even while nursing her newest baby. Thank you so much for all the
contributions and encouragement. I also want to thank Dr. Yinka Adeniran for his assistance
with data analysis. To my fellow colleagues in the Department, especially Dr. Bola Olusola-
Faleye, Dr. Alex-Okoh, Dr. Onwu, I say a big thank you for all your words of
encouragement, support and good wishes. God bless you all.
To Dr. Okey Idaboh, for being a wonderful and thorough facilitator, you made the Ibo
interpretation easy, humorous and interesting. To Dr. Lucy Idaboh and to all my field
workers and data collectors especially Ogadinma Iloh, thank you all so much for all your
contributions. It was a great experience working with you. To my wonderful and caring
siblings, especially Temi Atalabi Momodu and Tomi Atalabi, I say thank you for your
assistance, prayers and encouragement.
To my irreplaceable husband UZ, I say a big thank you for being a strong pillar of support in
my life, throughout the entire residency programme and this study. Thank you for your
understanding, care and love. I am extremely grateful.
To our lovely children, Uzo, Kika and Kobi who never missed saying these words during
every Morning Prayer; ‘’God please bless my mummy, may she pass her exams in Jesus
name’’ and to Uzo specially for always coming to my rescue whenever it seemed like I
wasn’t computer literate! Thank you all so much for being wonderful children and for coping
with having less of me throughout the period of this study and throughout the entire residency
programme. I love you all so much!
7
List of Abbreviations xi
Chapter Three: Materials and Methods 38
8
References 129
Appendix B: Theoretical proposition of the Health Belief Model 154
Appendix C: Map of Delta state showing the LGAs 155
Appendix D: Information Leaflet; Lesson notes (English language) 156
Appendix E: Information Leaflet; (Ibo language translation) 158
Appendix F: Information Leaflet; Flyer (English language) 160
Appendix G: Information Leaflet (Pidgin English language translation) 161
Appendix H: Photographic evidence of health education given 163
Appendix I: Ethical Approval 167
9
List of tables Page
Table 1: Socio-demographic characteristics of respondents (Tables 1a - 1e) 58
Table 2: Age and sex distribution of under-fives being cared for by the respondents 64
Table 3: Respondents’ awareness and major source of information of ARIs 65
Table 4: Respondents’ knowledge of symptoms of ARIs in under-fives 66
Table 5: Respondents’ knowledge of the cause of ARIs in under-fives 67
Table 6: Respondents’ knowledge of ways of preventing ARIs in under-fives 68
Table 7: Respondents’ awareness and knowledge of home management of 69
ARIs in under-fives
Table 8: Respondents’ knowledge of ARIs being a dangerous disease 70
and danger signs of ARIs in under-fives
Table 9: Respondents’ level of knowledge and mean knowledge scores of 71
home management of ARIs in under-fives
Table 10: Respondents’ attitude towards appropriate home-management 72
measures of ARIs in under-fives
Table 11: Respondent’s perception of fatality of ARIs in under-fives 74
Table 12: Respondents’ perception of severity of ARIs and signs serious enough 75
to seek medical attention
Table 13: Respondents’ perception of the effectiveness of antibiotics for the 76
treatment of simple/viral ARIs in under-fives
Table 14: Respondents’ attitude towards home-management of ARIs 77
in under-fives and their mean attitude scores
Table 15: Respondents’ practice of home-management measures for ARIs in 78
under-fives
10
Page
Table 16: Home management practices of respondents for under-five who 79
came down with ARI in the preceding month and were treated at home first
Table 17: Respondents’ level of practice of home management of ARIs 81
in under-fives and their mean practice scores
Table 18: Association between respondents’ age group and their level 82
of knowledge of home management of ARIs in under-fives
Table 19: Association between respondents’ level of education and their 83
level of knowledge of home management of ARIs in under-fives
Table 20: Effect of health education on respondent’s knowledge of symptoms of 84
ARIs in under-fives
Table 21: Effect of health education on respondents’ knowledge of the causes of 86
ARIs in under-fives
Table 22: Effect of health education on respondents’ knowledge of whether 88
ARIs can be prevented and ways of preventing ARIs in under-fives
Table 23: Effect of health education on respondents’ knowledge of ARIs 90
being a dangerous disease and knowledge of danger signs of ARIs in under-fives
Table 24: Effect of health education on respondents’ awareness of 92
home-management of ARIs in under-fives
Table 25: Effect of health education on the prevalence of ARIs and the 94
practice of home-management of ARIs by respondents on their under-fives
who came down with ARI in the preceding month
Table 26: Effect of health education on respondents’ practices of appropriate 96
home-management of ARIs in under-fives in the preceding month
11
Table 27: Effect of health education on respondents’ practice of inappropriate 98
home-management of ARIs in under-fives in the preceding month
Page
Table 28: Effect of health education on respondents’ level of knowledge of 100
appropriate home- management of ARIs in under-fives and their mean
knowledge scores
Table 29: Effect of health education on respondents’ attitude towards 102
appropriate home-management of ARIs in under-fives and their mean
attitude scores
Table 30: Effect of health education on respondents’ level of practice of 104
appropriate home-management of ARIs in under-fives and their mean
practice scores
List of figures
Figure 1: Photographic evidence of health education given to the caregivers 163
in the intervention group using a flipchart
Figure 2: Photographic evidence of health education given using the flipchart 164
Figure 3: Photographic evidence of the researcher handing out information 165
leaflets and pamphlets to the caregivers
Figure 4: Photographic evidence of the researcher educating the caregivers 166
on the benefits of adequate nutrition in the management of ARIs in under-fives
using a flipchart
LGA – Local Government Area
PHC – Primary Health Centre
LBW – Low Birth Weight
HiB – Heamophilus Influenza B
HIV – Human Immunodeficiency Virus
SFU – Solid Fuel Use
ETS – Environmental Tobacco Smoke
OAP – Outdoor Air Pollution
SES – Socio Economic Status
NO2 – Nitrogen dioxide
SO2 – Sulphur dioxide
SCHEWs – Senior Community Health Extension Workers
JCHEWs - Junior Community Health Extension Workers
SUMMARY
Introduction – Acute respiratory infections (ARIs) are one of the leading causes of under-
five mortality especially in developing countries. Caregivers play a major role in the
management of under-five ARIs. The aim of this study was to assess the effect of health
education on caregivers’ knowledge, attitude and practice of appropriate home management
of ARIs in under-fives in Issele-Azagba, Delta state.
Materials and methods - A non-randomized, controlled intervention study was carried out
among 139 caregivers of under-fives in Issele-Azagba, Delta state using 139 caregivers of
under-fives in Ekwuoma community also in Delta state as controls. The respondents were
selected using a multi-stage sampling method from both groups. Baseline data was collected
using a pre-tested, semi-structured, interviewer administered questionnaire. A health
education programme based on the ‘Health Belief Model’ was carried out among the
caregivers in the intervention group using a video clip, flipchart, role plays, health talks,
information leaflets and posters. Post-intervention data collection took place three months
later. Epi-info 2008 version was employed in the data analysis.
Results – A total of 278 caregivers of under-fives participated in the baseline study.
Awareness of home-management of ARIs among the respondents increased from 78.4% at
baseline to 100% post intervention in the intervention group and from 88.5% to 89.2% in the
14
control group. All the respondents (100%) in the intervention and 98.6% in control groups
respectively had poor level of knowledge at baseline. Majority of the respondents (97.1% in
the intervention group and 86.3% in the control group) had negative attitude towards home
management of ARIs at baseline. Also, majority of the respondents (94.2%) in both
intervention and control groups respectively had poor level of practice of appropriate home
management of ARIs in under-fives at baseline. Under-fives with symptoms of ARI were
dressed in warm clothes when it was cold by 26.5% and 21.6% of respondents in the
intervention and control groups respectively. None of the respondents in the intervention
group and 2.7% in the control had practiced steam inhalation. Only 2.4% of the respondents
in the intervention group and 9.5% in the control group had given the sick child warm drinks.
Only 2.4% and 2.7% in the intervention and control groups respectively had washed their
hands with soap and water in association with managing under-five ARIs at home. Regarding
inappropriate management, majority of the respondents (75.9% in the intervention and 56.8%
in the control group) had inappropriately given antibiotics and 68.8% in the intervention and
54.1% in the control group respectively had given cough syrup for the treatment of common
cold/viral ARIs at home. Post intervention, in the general performance score, there was a
statistically significant increase of 41% in the proportion of respondents with a better level of
knowledge in the intervention group from baseline. (P<0.05) Also, the proportion of
respondents with positive attitude increased significantly by 77% from baseline. There was
also a statistically significant increase in the proportion of respondents with a better level of
practice in the intervention group by 30.9% from baseline. There was no statistically
significant positive change observed in the awareness, knowledge, attitude or practice of the
respondents in the control group, post intervention.
15
Conclusion: The health education programme was effective at improving the knowledge,
modifying the attitude and improving the practices of caregivers regarding appropriate home
management of ARIs in under-fives in the intervention group.
Recommendations: To strengthen community health education of caregivers especially
mothers and to train community resource persons on appropriate home management of ARIs
in under-fives. These interventions should be aimed at prevention, identification danger signs
and timely home-management of ARI cases.
CHAPTER ONE
1.1 INTRODUCTION
Acute respiratory infections (ARIs) are the most common infections among humans, and are
one of the leading causes of death in young children under five years of age in developing
countries.1 ARIs are common in all seasons, but incidence is highest between July and
October and between January and March.2 They occur at an average of four to nine episodes
per child annually, translating to at least 200 million episodes each year causing morbidity
and disability.3 They are responsible for over four million out of the estimated fifteen
million premature deaths that occur in children under the age of five years each year in
developing countries4
ARIs consist of acute upper respiratory tract infections (AURIs) such as infections in the ear,
nose and throat, and acute lower respiratory tract infections (ALRIs) which are infections of
the epiglottis, larynx, trachea, bronchi, bronchioles and lungs.4 They range from mild, self-
limiting infections of viral origin such as coughs and colds for which there is no cure, to life
16
threatening diseases such as severe pneumonia which can be effectively treated with short
term, low cost antibiotics.5
About one in every 30 to 50 episodes of cough will develop into pneumonia. Without
treatment, 10% to 20% of pneumonia cases will result in death. Each year, pneumonia alone
kills 3 million children under the age of five years, while other ARIs cause another 1 million
deaths in children. Many of these deaths occur during the first year of life and at home.4, 6
ARIs can be attributed to an interaction between the host, the infectious agent, and the
environment. While respiratory viruses are the predominant cause of ARIs, especially in
developed countries, there is strong evidence that bacteria cause a large proportion of
childhood pneumonia in developing countries.5
Despite the predominantly viral cause of ARIs, 7, 8, 9 many children with ARIs are treated at
home with over the counter cough and cold remedies which are of no benefit, can be
potentially harmful and are a drain on financial resources.5 Also, the inappropriate treatment
of simple/viral ARIs with antibiotics is a major worldwide problem clinically and
economically. The drugs used are either of poor quality, inappropriate for the illness, or
improperly administered. The consequences include preventable mortality and morbidity
from treatment failure, unnecessary adverse effects of the antibiotics, waste of health care and
family resources, and an increased emergence of bacterial resistance.10
Home-based management of ARIs entails identifying and diagnosing symptoms and signs of
ARIs, providing appropriate preventive and comfort measures at home, and observing a child
with ARI closely and taking the child to a health facility/worker immediately for treatment if
any danger signs occur.11 Mothers and caregivers play an important role in observing changes
in their child/children’s health. Studies have reported that mortality in children due to ARIs
17
could be reduced by one-half. If danger signs, such as fast breathing and chest in-drawing
were recognized early by caregivers at home, timely and appropriate treatment would be
sought.12, 13, 14
Utilization of health facilities remains low in many parts of the world and children are treated
at home through the informal sector or by traditional healers. Studies consistently confirm
that many sick children do not reach health facilities, and children from poorer families are
even less likely to obtain care. Poverty, overcrowding, air pollution, malnutrition, harmful
traditional practices, delayed and inappropriate case management are reasons for high case
fatality rates from ARIs15,16 17.
JUSTIFICATION FOR THE STUDY
The United Nations Children’s Fund (UNICEF) set a target of 33% reduction in child deaths
caused by ARIs by the year 2000.4 One of the strategies for achieving this reduction is
educating the mothers and caregivers about ARI management at home. As the first health
decision makers, mothers and caregivers can decide when and where to seek treatment, when
to initiate antibiotics treatment or limit their unnecessary use. Providing caregivers with
information about recognizing danger signs and appropriate management of ARIs would
vastly improve their ability to care for their children and enable them make correct
decisions.16,18 The high incidence of infectious disease in children can be attributed to lack of
access to health care, high cost and poor regulatory controls on the use of prescription drugs
such as antibiotics coupled with low antibiotics knowledge of the caregiver.19, 20, 21
Issele-Azagba village is one of the 18 communities in Aniocha North Local Government
Area (LGA) in Delta state, Nigeria. The community lacks geographical access, amongst
other factors (such as financial factors) to an appropriate health care facility as there is no
18
Primary Health Centre (PHC) within a 5Km radius of where the people live. Hence, a
suitable health care facility which provides appropriate services for managing childhood
illnesses is a challenge in this community. There is however only one Health Post/Dispensary
which provides mainly maternity and delivery services, and there are a few Patent Medicine
Vendors in the village. The lack of these appropriate health care facilities often distorts the
health seeking behaviour of caregivers in this community, and usually forces them to manage
their sick children at home.
Gaining a better understanding of these caregivers’ home management of childhood ARIs
and the factors which influence their knowledge, attitude and practice in this setting, will
enable health policy makers plan and provide appropriate educational interventions.112 This
will help to reduce mismanagement of ARIs and its consequences, in the community being
studied in particular and the country in general.
A meta-analysis of studies done showed that community health education sessions targeted at
mothers in particular are effective in ensuring proper management of childhood ARIs and
consequently reduction in ARI mortality.22
This study will employ the use of health education sessions and will aim to improve
caregivers’ ability to recognize danger signs of ARIs, differentiate mild ARIs from severe
ARIs, and know when and where to seek medical care and also to know the importance of
complying with prescribed treatment. It will assess the effect of health education on the
knowledge, attitude and practices of children’s caregivers in Issele–Azagba community in
Delta state regarding appropriate home management of ARIs in children under five years old.
19
GENERAL OBJECTIVE
To reduce under-five deaths from Acute Respiratory Infections (ARIs) in Issele - Azagba
community in Delta state
SPECIFIC OBJECTIVES
1) To assess the level of knowledge and attitude of caregivers on home management of
ARIs in the under fives in Issele-Azagba community;
2) To determine the practice of caregivers regarding home management of ARIs in the
under fives in Issele-Azagba community;
3) To provide health education to the caregivers on appropriate home management of
ARIs in the under fives in Issele-Azagba community; and
4) To assess the effect of the health education on the knowledge, attitude and practice of
caregivers on appropriate home management of ARIs in the under fives in Issele-
Azagba community.
EPIDEMIOLOGY OF ARIs
Acute respiratory infections (ARIs) are the most common infections among humans and one
of the leading causes of death in young children under five years in developing countries.1
ARIs are common in all seasons, but incidence is highest between July and October and
between January and March. 2
Respiratory infections include infections in any area of the respiratory tract. Upper ARIs
(AURIs) include infections in the ear, nose or throat, while lower ARIs (ALRIs) include
infections in the epiglottis, larynx, trachea, bronchi, bronchioles and lungs. The common
acute infections of the upper and lower respiratory tract range from a simple cold or cough,
otitis media, sore throat, laryngitis, to bronchitis, bronchiolitis, and pneumonia. Diphtheria,
measles, and pertussis (whooping cough) are also respiratory infections. 4
ARIs include all of the above conditions when they are of less than 30 days duration, the
exception being acute ear infection (only considered an ARI if of less than 14 days
duration.18, 23, 24 They range from a self-limited illness, such as a cold, to life-threatening
diseases such as severe pneumonia. There are three categories of ARI. ‘’Non pneumonia;
21
cough or cold’’, ‘’pneumonia’’ and ‘’severe pneumonia’’.4 Distinguishing among the three is
important because the treatment will depend on this determination. Signs and symptoms for a
simple uncomplicated cough or cold, when pneumonia is not present include runny nose,
sneezing, sore throat, headache, cough and possibly fever. Signs and symptoms for
pneumonia include fast or rapid breathing, difficulty in breathing, possibly with fever and
cough. Breathing is considered to be rapid when Respiratory Rate is 60 breaths per minute or
more in a child of less than 2 months old, 50 breaths per minute or more in a child of 2 to 12
months, and 40 breaths per minute or more in a child of 13 months to 5 years old.4
Management of ARIs is aimed at treating the cause of the infection (bacteria), in the case of
pneumonia, or managing the symptoms in the case of a viral cough or cold. 4
MORBIDITY AND MORTALITY FROM ARIs
Pneumonia constitutes a major proportion of the global burden of childhood disease
responsible for around 20% of childhood deaths, especially in developing countries.25, 26, 27, 28.
Annually, almost half of the 1.9 million deaths due to ARIs in children under the age of five
years occur in Africa. 29
According to 2005 World Health Organization (WHO) estimates of the distribution of causes
of childhood deaths, infections alone are responsible for 18.1% of childhood deaths globally.
The percentage of children dying from pneumonia varies from 15 to 26% depending on the
region of the world and the under 5 mortality rates. The largest part of these deaths were due
to pneumonia (including neonatal pneumonia), either as an underlying cause or as a result of
infections complicating measles, pertussis or AIDS. Other contributing factors associated
with a large number of pneumonia deaths are low birth weight and severe malnutrition.29
AETIOLOGY OF ARIs
Bordetella pertussis, Streptococcus pneumonia and Heamophilus influenzae. Most cases of
severe pneumonia among children in developing countries are caused by bacteria. About 65-
75% is due to Streptococcus pneumoniae or Heamophilus influenzae and another 10% is due
to Staphylococcus aureus in contrast to developed countries, where most pneumonia among
children are viral. Not uncommonly, more than one pathogen may be involved however. 4
ASSOCIATED RISK FACTORS FOR ARIs
Risk factors that encourage the spread of ARIs include: low birth weight, malnutrition, poor
breast-feeding practices, specific nutritional deficiencies (especially Vitamin A), chilling in
young infants, indoor air pollution (such as smoke from cooking fuels and tobacco), urban air
pollution, illiteracy, overcrowding, poor hygiene, lack of access to health services (especially
immunizations), and low socioeconomic status. Many of these risk factors may interact
through complex mechanisms to cause subsequent illness. 4
The socio-demographic characteristic of mothers/caregivers – The socio-demographic
characteristics of mothers like age, education, occupation, income, marital status, family size
and area of residence are known to influence the incidence and prevalence of ARI in their
under five children, either positively or negatively. 30, 31 32, 35
Children from large- sized, low income families with less educated mothers have a higher
risk of ARI than their counterparts from small-sized, high income families with more
educated mothers. In a cross sectional study of Bangladeshi mothers and their infants,
Rahman and Shahidullah found that children of young (less than 20 years), working mothers
with low education and income had a high risk of ARIs.34 Similar findings were made by
Vathanophas and colleagues in Thailand, 33 Muhe and co-workers in Ethiopia,36 Berata and
colleagues in Brazil.37 However, with regards to parental education, contrary findings were
23
made by Cruz and colleagues who reported higher rates of ARI among children of better-
educated Guatemalan families.38 This evidence was corroborated by a meta-analysis of study
results from ten developing countries, including Nigeria, which revealed that, contrary to
popular opinion, ARI was not high among children of less educated mothers. 39
Regarding maternal age, a study found ARI to be more prevalent among children of older
mothers (aged 35 years and above) in Saudi Arabia, contrary to findings in other countries.40
Only the study by Shamebo and colleagues in Ethiopia mentioned maternal ethnicity as a
factor associated with ARI in under-fives.35 The incidence of ARI has been noted to be higher
among children of mothers with history of allergies, than among those mothers without
history of allergies. 33
Many factors, most modifiable are related to the risk of children contracting and dying from
pneumonia and other ARIs. Low birth weight remains an important risk factor, as does poor
nutrition; indoor environmental conditions, e.g., crowding, smoke from cooking and
environmental tobacco smoke, also raise the risks of severe pneumonia. While
microorganisms are the most important cause of pneumonia in children, several important
aspects of the child's environment (risk factors) and of the child's makeup (endogenous
modifiers) have been identified;
Aspects of the child's makeup (host factors; endogenous modifiers) that increase the
chance of getting pneumonia:
Sex - There is a slight difference in the frequency and severity of ARIs between girls and
boys: it is more common and the symptoms are more severe in boys especially in younger
age groups. Fagbule reported that more children with acute lower respiratory infections,
whether inpatients or outpatients are boys, ranging from 55 - 60% of cases in most studies.30
Cruz and colleagues reported a prevalence of 56% in males and 44% in females. 38 Similar
24
findings were made by Vathanophas and colleagues in Thailand, 33 Sutmoller and Maia in
Brazil, 41 and Bashour and colleagues in Syria.42 A comparison of findings from ten
developing countries, including Nigeria by Selwyn and colleagues agrees to earlier reports of
male preponderance in the prevalence of ARIs, although case fatality rates are somewhat
higher for girls than boys.39 However, Rahman and Shahidullah did not find any sex
difference among Bangladeshi children.34
Age - Pneumonia occurs more frequently among infants below 1 year of age and decreases
steadily with age during childhood. Infants are more likely to die from pneumonia. The
younger the child the more likely the pneumonia will lead to death.43 In Nigeria, the ARI
rates are highest in children aged between 12 - 23 months. 30 Young infants are the most
vulnerable to ARIs partly because of their immature immune system and partly because the
birth process exposes babies to infection through their newly functioning lungs and healing
umbilical stumps.30, 44, 45
Low birth weight (LBW) - Infants below 2.5 kilograms at birth are more prone to infections
and more likely to die from pneumonia during the first year of life than infants with normal
weight at birth. While LBW is itself an important cause of childhood mortality, it is also
associated with ALRI morbidity and mortality. 46, 47
Victora et al reviewed four studies of ALRI mortality and LBW and found a pooled estimate
of 2.9 times increased risk of death for children with birth weight <2500g.46 There is also
consistently increased incidence of ALRI in LBW infants in almost all studies with relative
risks between 1.4 and 3 times, depending on the severity of LBW. 46, 47, 48 LBW may be
associated with increased risk of ARI due to its association with other measures of socio-
economic deprivation as well as because it may lead to shorter duration of breastfeeding and
poorer nutritional status, both of which are independent risk factors for ARI.46 Nevertheless,
25
the associations between LBW and ARI morbidity and mortality are robust to adjustment for
confounding, and there are other mechanisms by which LBW in itself may predispose to
ARI, namely reduced immune competence and impaired lung function. 46
Breast-feeding practices - There is a marked difference in occurrence of pneumonia
between infants who are breast-fed and those who are not. Not only is pneumonia more
common, but higher proportions of infants die of the disease if they are not breast-fed. A
review of studies associated with ALRI from developing countries and/or low-income
populations in developed countries, found consistently increased risk of ALRI among
children who were not breastfed or partially breastfed compared to exclusively breastfed
children, again with a dose-response relationship.46 The risk of ARI is increased by
approximately 60% in children who are never breastfed, while nonbreastfed children are
between 2-3 times more likely to die from ALRI compared to those who are breastfed.. 46, 48,
49 The relative importance of this risk factor is obviously dependent on local breast feeding
practices. A study carried out in the Western Cape of South Africa; found that 24% of
children are never breastfed with a further 19% being breastfed for less than 6 months. 50
The protective effect of breastfeeding is primarily due to its unique anti-infective properties,
providing passive protection against pathogens, stimulating the infant’s immune system and
inhibiting gastro-intestinal colonization by Gram-negative species. 48
In low-income settings, exclusively breastfed babies may have better nutritional status
during the first few months of life and are less likely to be exposed to contaminated foods,
and thus less likely to contract gastro-enteritis, which would have further impaired the
nutritional status. 46, 47 Interestingly, the protection afforded by breast-feeding against ALRIs
persists well beyond the breastfeeding period. 46
26
Malnutrition - Children who are severely and chronically malnourished are up to 10 times
more likely to develop pneumonia and die of it than well-nourished children.46 Numerous
studies in developing countries, particularly in South America and Asia, have shown
consistent, significant and dose-response relationships between malnutrition and both
incidence of, and mortality due to, ARI in children.46, 48, 49 In Fortaleza, Brazil, for example,
moderate and severely underweight children were 4.6 times more likely to develop
radiologically confirmed pneumonia compared to adequately nourished counterparts, while
mortality studies have shown malnourished children to have between 2 and 25 times the risk
of death from pneumonia. The dose-response relationship found in almost all studies is
notable in showing that even relatively mild degrees of malnutrition, increases the risk for
ARIs.46
The increased risk and severity of ARI associated with malnutrition is biologically plausible,
as malnourished children are known to have impaired immunological (particularly cell-
mediated) responses and more severe infections. Malnutrition is itself both a cause of under-5
mortality as well as a risk factor for incidence of and mortality due to other major causes of
under-5 mortality such as diarrhoeal disease and HIV-infection. 46
Low immunization coverage - Infectious diseases such as measles and whooping cough also
increase the occurrence of, and death from, pneumonia. Pneumonia is more frequent where
children are less likely to get diphtheria, pertussis and tetanus (DPT) and measles vaccines. In
such situations, the frequency of pneumonia in children could be reduced by 10-20% through
immunization with these vaccines. Additional important reductions can be achieved through
immunization with the Heamophilus influenzae type b vaccine and the new pneumococcal
conjugate vaccine for children. 52
27
Global immunization programs through the Expanded Program of Immunization (EPI) have
produced a decline in measles pneumonia and childhood pertussis. A recent survey in the
Western Cape of South Africa found that overall vaccine coverage was 80%, 77% and 48%
for vaccines due by 14 weeks, 9 months and 18 months respectively. A significant number of
children are therefore not even receiving their early vaccines, while a large proportion of
children are not receiving full courses of Diphtheria, Pertussis, Tetanus (DPT) and measles
vaccines. 52
Nigeria is yet to include the Heamophilus influenzae type b (HiB) vaccine into the national
guidelines of immunization.6 Cost is however a major challenge to the adoption of the new
generation of childhood conjugates bacterial vaccines, such as the pneumococcal conjugate
vaccine, into the EPI schedules in developing countries. Furthermore, investment is required
to ensure that the most vulnerable children have access to vaccines by development of the
infrastructure and resources required for a successful vaccine programme.52
Micronutrient deficiency - Rickets, a condition caused by deficiency of vitamin D, is
associated with a high incidence of pneumonia however there are conflicting reports
concerning vitamin A supplementation in respect to ARI. A study on the efficacy of high
doses of ALRI using a randomized, double-blinded placebo controlled trial showed neither a
statistically, nor clinically significant difference by treatment or control group in the rate of
normalization of respiratory rate, temperature or clinical score. Adverse scores were equally
distributed between the two groups. It was concluded that treatment with high doses of
vitamin A over and above the standard dose for infants and children with non-measles related
ALRI is not efficacious for the current episode. 53
However, daily prophylactic elemental zinc, 10 mg to infants and 20 mg to older children
may substantially reduce the incidence of pneumonia, particularly in malnourished children.
28
A pooled analysis of randomized controlled trials of zinc supplementation in children in
developing countries, found that zinc-supplemented children had a significant reduction in
pneumonia-incidence compared to those receiving placebo[OR of 0.59 (95% CI 0.41 to
0.83)]. 54, 55
HIV infection - Children infected with the human immunodeficiency virus (HIV) are much
more likely to develop and die from pneumonia because of the reduced immunity caused by
the HIV. 56, 110, 111
Previous infections - Children with a history of previous exposure to, and infection with,
respiratory viruses are much more likely to develop bacterial pneumonia.
Chronic non-infectious illness - Children with congenital abnormalities or chronic
debilitating conditions such as cerebral palsy, Down syndrome, severe gastro-oesophageal
reflux or congenital heart disease are at increased risk of recurrent pneumonia.
ASPECTS OF THE ENVIRONMENT THAT INCREASE THE CHANCE OF
GETTING PNEUMONIA;
Exposure to indoor air pollution, including environmental tobacco smoke - In many low-
income countries traditional ways of cooking and heating using solid fuels are common.
Cooking is often done indoors in poorly ventilated rooms leading to high levels of pollution
due to smoke. The occurrence of pneumonia increases in direct relation to the amount of time
a child spends exposed to this type of pollution. Young infants carried on the backs of
mothers are especially at risk while their mothers do the cooking. Children exposed to
tobacco smoke from people around them who smoke are more likely to develop pneumonia;
the more people who smoke in the household of a child, the more likely it is that the child
will develop pneumonia. A study done in the Gambia found that carriage of children on their
29
mother’s back while cooking and the number of cigarette smoked by their fathers were the
risk factors associated with ALRIs.57
Biomass fuels produce small amounts of energy but large amounts of indoor pollutants, often
emitting 50 times more pollutant concentrations than energy equivalent natural gas.47
Housing characteristics in developing countries with poor ventilation and dispersion may
exacerbate pollutant concentrations.58 Studies done in very low and low income communities
in an Eastern Cape township, for example, found levels of NO2 and SO2 to be 7 times and 13
times higher respectively than the risk-free levels considered acceptable. 59
Air pollutants associated with Solid Fuel Use (SFU) may adversely affect specific and non-
specific host defenses of the respiratory tract against pathogens and, while smoke from SFU
is a complex and variable mixture containing a number of potentially toxic substances about
which only broad generalizations can be made, there is sufficient understanding of the
toxicological properties of these mixtures for them to plausibly increase risk of ARI. 60
Children are particularly vulnerable to the hazardous respiratory effects of SFU because of
the large amount of time spent with their mothers doing household cooking. 60 There is strong
international evidence from developing countries, especially Africa, linking Solid Fuel Use
with increased incidence and severity of ARI in children less than 5 years. 49,58,60,61
In a review of 13 studies from developing countries, 60 almost all studies found positive
associations between Solid Fuel Use and ALRI in children. Solid Fuel Use was associated
with approximately twice the risk of ARI. In the single study examining mortality, the risk of
death from ARI was increased 12 times in those exposed to SFU. In addition, Pandey et al
showed a dose response relationship between maternally reported time spent near the cooking
stove and ARI.62 In a local Eastern Cape study, increased incidence of ARI was ecologically
linked with communities in which indoor air pollutants were highest. 59
30
Environmental tobacco smoke (ETS) and maternal prenatal smoking - More than 150
studies have been published linking ETS to respiratory illness in children, with meta-analyses
finding strong evidence for associations between both prenatal maternal smoking and
postnatal ETS exposure and risk of ARI in children.63
In a review of 38 studies, 64 the researchers found all but one to be consistent with an
increased risk of ARI for children exposed to parental smoking, with pooled ORs of 1.57
(95% CI 1.42 to 1.74) for smoking by either parent and 1.72 (95% CI 1.55 to 1.91) for
maternal smoking. Risk of chest illness was also increased if household members other than
the child’s parents smoked. (OR: 1.29, 95% CI 1.16 to 1.44). When limited to children under
5 years, the effect is even more marked with an OR of 2.5 (95%CI: 1.86-3.36). 58 These
associations with parental smoking are maintained after adjustment for confounding factors,
and there is evidence of a dose-response relationship. 58
Several reviews have concluded that the relationship between ETS exposure and ARI in
children is likely to be causal and as a result of a direct adverse effect on the child’s
pulmonary function , and not simply due to the parents themselves being more likely to
acquire and thus transmit ARIs in the home. In addition to the increased risk of ARI
morbidity among children exposed to ETS, there is also an increased risk of hospitalization
and mortality. 58, 63
Maternal smoking during pregnancy appears to further increase the risk of ARIs associated
with ETS exposure, with term infants dying from respiratory disease being 3.4 times more
likely to have had mothers who smoked during pregnancy. This effect was not simply
attributable to differences in birth weight between infants of smokers and nonsmokers. 63, 64
Outdoor air pollution (OAP) - Episodes of OAP in developed countries have been
associated with significant increased mortality, and it has been suggested that children are
31
particularly at risk from extreme pollution. Evidence from a number of studies supports
concern that exposure to pollution, especially fine particles and ozone, increase risk of ARI in
children. Air pollutants adversely affect immune function and cause inflammatory reactions,
which may increase susceptibility to bacterial infection. 65
OTHER RISK FACTORS OF ARIs INCLUDE;
Crowding - Crowding of any sort increases the possibility of respiratory infection because
the number of microorganisms in the air the child breathes is much greater when larger
numbers of people are crowded into small spaces. Many children are exposed to very
crowded conditions at home, and this increases risk of transmission of illness. Most studies in
developing countries have found that the average area of habitable space per person is well
below the WHO recommendation of 12m2. 66
In a case-control study in Sao Paulo, Cardoso et al, found crowding (≥ 4 people sharing the
child’s bedroom) to be associated with 2.5 fold increased risk of ALRI, with cases tending to
live in smaller houses than controls.41 Other studies from developing and developed countries
have found similar effects both for crowding and number of siblings. 47, 48, 59, 67, 68
Crowding is as a result of both larger family size and smaller, poor quality housing. These are
both associated with poor socio-economic status, which itself exacerbates crowding with
more than one family unit sharing a single dwelling. Crowding may also occur outside the
home in day care centers. Numerous studies in both developed and developing countries have
shown children attending day care centers to be at increased risk of both acquiring upper and
lower ARI, 44, 69, 70, 71 as well as needing hospitalization for ARI. 72 Risk of acquiring ARI in
day care centers is particularly increased for younger children (less than 18 months of age)
32
and those with poorer access to health care services. 69 Specifically in a developing country
context, incidence of ARI increases with the proportion of time since the child was born that
the mother has been working 48
Sanitation - Cardoso et al. 66 found children with respiratory illness to come from houses
with poorer sanitation than controls, while in developed countries promotion of hand washing
has been associated with reduced incidence of respiratory illness 69
Housing quality - Poor quality housing is defined in various ways by different studies and
thus it is difficult to determine effects of specific housing characteristics across a number of
studies. Nevertheless, there is consistent evidence that damp and humid conditions are
associated with ARIs in children, studies also found a composite poor housing status score,
was associated with increased incidence of ARI. 67, 68, 73
Socio-economic status (SES), including poverty and lack of education - SES is measured
in different ways by different studies and includes, inter alia, components of status, income,
education and housing. Poverty and low SES are associated with so many other independent
risk factors for ARIs, such as overcrowding, poor sanitation, poorer access to medical care,
poorer immunization coverage, malnutrition, poor housing, LBW and Solid Fuel Use, that it
is difficult to tease out the effect of low SES per se. Interestingly, after adjusting for many of
these known risk factors, many studies have found no residual effect of low SES, however
this may in part be due to the lack of diversity in SES within these studies. 48, 49
Nevertheless, the underlying influence that low SES has on many of the known risk factors
for ARI makes it an important factor to consider, particularly when seeking interventions to
reduce ARI incidence and mortality. Some studies have found associations between SES and
parental education and ARI incidence but these have not been consistent or robust to
adjustment for confounding.47 However, a review by Von Ginneken et al found strong
33
relationships between ARI mortality and maternal education consistent across a number of
studies. The authors estimate that approximately half of this effect is related to the economic
advantages afforded to better educated mothers. These may be attained both through women
increasing their own earnings and because educated women are more likely to marry
educated and wealthier men. Apart from its economic impact, maternal education was found
to have little effect on crowding and indoor air pollution, but to dramatically increase the
health care use. There is thus a more appropriate response when pneumonia occurs, hence
effects on mortality. 74
Interestingly, studies carried out in the Gambia found children of mothers with a personal
source of income to be at lower risk of ALRI. This highlights the dilemma faced by mothers
who while enhancing their children’s health by increasing their income through working,
may paradoxically place their children at risk by the required shortening duration of
breastfeeding and placing children in daycare centers from a young age. 75
INTERVENTIONS
Existing and potential interventions that address the risk of ARI morbidity and mortality in
young children can be grouped into, targeted interventions; specific interventions that address
specific risk factor; and broader interventions that address a number of risk factors and may
have far reaching health impacts beyond ARI and even childhood illnesses in general.
Ehiri and Prowse proposed that for real effects on childhood mortality, interventions cannot
be limited to the health sector, but need to address environmental and societal factors
underlying childhood diseases.76
Specific risk factor interventions have been carried out to address malnutrition, low birth
weight and lack or inadequate breastfeeding as they are major risk factors of morbidity and
mortality in childhood ARI. 25, 46, 77, 78
Interventions to address the suboptimal vaccine coverage in Nigeria need to be sought.
Furthermore, consideration should be given to adding the pneumococcal conjugate vaccine to
the Nigerian routine vaccine schedule. Because of cost-constraints and other factors, this
vaccine has not yet been included in the Expanded Programme on Immunization (EPI)
program and hence remains inaccessible to the majority of Nigerian children. However, it has
great potential to reduce the burden of ARI in children as pneumococcus remains the major
cause of bacterial pneumonia and death in children under 5 years.79 Results have been
reported by a Gambian study, where in addition to reducing the incidence of radiologically
confirmed pneumonia by 37%, the vaccine was also found to reduce all-cause childhood
mortality by 17%. 80
A cost-effectiveness analysis by Sinha et al showed that pneumococcal vaccine at a price of
up to $5 per dose would be highly cost effective in almost all of 72 developing countries
included in the study. Advocacy for reduction in the price of the vaccine and inclusion in the
EPI schedule should therefore be a priority.81
Environmental tobacco smoke (ETS) exposure remains a major risk factor for childhood
ARI. Measures to reduce ETS exposure in public places (e.g. regulation of tobacco industry
and advertising, legislation forbidding smoking in public places etc) should be in place in
every country. A Cochrane review of 18 studies on ‘’Family and Carer Smoking Control
Programmes,’’ found reductions in reported or actual ETS exposure in both intervention and
control groups in 12 of the 18 studies, but statistically significant better results for the
intervention group only in 4 studies. Programmes with intensive counseling tended to work
35
better, as did those that focused on participants’ attitudes and behavior rather than change in
knowledge. The context of the intervention (well child, respiratory ill child, non-respiratory
ill child, peripartum) did not affect success of the programme. Smoking cessation
interventions perhaps targeted to certain groups e.g. antenatal attendees, school attendees may
be of benefit. 82
An economic analysis by Leiman et al 83 found that interventions at household level to reduce
air pollution had the greatest impact on health and were thus the most cost effective at
reducing health care costs. They argue that further industry controls are not justifiable at this
point.83, 84 Housing improvement and consequent reduction in overcrowding can go a long
way in reducing morbidity and mortality due to ARI. 85 A recent study in squatter settlements
in Pakistan points to a simple and potentially extremely effective measure to reduce ARI
incidence. In a community randomized trial in households receiving hand washing promotion
and free plain soap, children under 5 years had a 50% lower incidence of pneumonia
compared to those from control households. Incidence of diarrhea was also halved. The
reduction in pneumonia particularly affected the winter peak incidence, and, notably, the
intervention was effective regardless of the children’s nutritional status. Effective hand
washing implies that people have access to running water. Therefore access to running water
should be a primary objective for all households. Although results from a trial setting do not
necessarily extrapolate to effectiveness in large-scale roll out, but hand washing and
provision of soap nevertheless may be a potential “magic bullet” in reducing ARI and
diarrhea incidence. 69
Von Ginneken et al. showed that reduction in post-neonatal mortality (a large proportion of
which is known to be due to ALRI) in 8 developing countries closely reflected improvements
in maternal education (regular schooling received by a woman) over a 15 year period. They
36
thus predicted that worldwide improvements in maternal education over the next 15 years
could result in reductions of pneumonia mortality of between 2 and 11% depending on the
existing level of education in a given context. It is also important in measuring outcomes, to
be aware that maternal education is of course a long-term investment, with the benefits in
terms of child health and survival only being gained by the next generation. 74
Since poverty underlies so many risk factors for ARI and other childhood as well as adult
causes of morbidity and mortality, measures to address it are critical to improving the health
status of all people, but particularly children. 84
Broader interventions such as Integrated Management of Childhood Illness (IMCI) have
shown that improvement of maternal health, immunization and nutritional rehabilitation is
very effective. Use of case management guidelines for treatment of childhood pneumonia can
significantly reduce overall and pneumonia-specific mortality in children less than 5 years.22.
A Nepalese ARI control programme reported similar success with case management.63
However it was found that while a health sector specific programme including health
education, immunization and case management resulted in substantial reductions in ARI-
specific death rates, there was still unacceptably high mortality from malnutrition, chronic
diarrhoea and other factors, many of which themselves impact on ARI incidence and severity.
This study points to the need of managing and controlling many of the major killer diseases
of children. 62
MANAGEMENT OF ARIs
Once a child is ill, death can come very rapidly. Lack of recognition by the mothers or
caregivers of the severity of the situation, and delays or difficulties in getting care can mean
the difference between survival and death, which often occurs from 2-3 days after the onset
of symptoms. 4
37
The World Health Organization (WHO) established a global ARI Programme in 1982 to
promote the early detection in the community and treatment of in particular pneumonia.
Scientific studies subsequently showed that a reduction of mortality from ARI by
approximately 50 percent could be attained using standard case management. (SCM)
The main objective of ARI control activities is “to reduce mortality from pneumonia in
children under the age of 5 years” while in addition, ARI control is intended to achieve three
other objectives: 4
To reduce the inappropriate use of antibiotics and other drugs in the treatment of ARI
in children;
To reduce the severity and avoid complications of acute upper respiratory infections
in children (deafness subsequent to otitis media; rheumatic fever and heart disorders
subsequent to streptococcal pharyngitis);
To reduce the complications of acute lower respiratory infections (pneumonia,
bronchiolitis) through early diagnosis and effective case management.
Strategies
Standard case management (SCM) is the primary specific strategy available for the
achievement of the ARI control objectives. However, there are also several general strategies
that may be helpful for accomplishing the objectives. These include immunization against
measles and pertussis and prevention of risk factors. Later in the 1990's, the WHO promoted
the integration of the ARI programme.4 Other elements of supportive care include;
Home care- Supportive care at home consists of fluids, continued feeding, neutral
environmental temperatures, clearing the nose and upper airway passages. It also involves
giving paracetamol for fever and relief of ear pain, and safe, soothing non-commercial throat
and cough remedies such as a mixture of honey and water. 7 Advise to mothers on home care
38
includes; Feeding the child, Continue to feed the child during the illness and increase feeding
after illness; Clear the nose if it interferes with feeding; Use saline nose drops for blocked
nose;
Develops difficulty in breathing and chest in drawing
Is not able to drink
Has a fever which does not settle
Develops fast breathing
Becomes sicker
All the above infer that the child may be developing severe pneumonia and will need referral.
Caregivers should be reminded that cough mixtures are of no proven value, and the child
should be followed up thereafter. 7
Hospital care - Hospital supportive care may include oxygen treatment and fluid
management, in addition to the measures recommended for home care. 7
Immunization - Immunization focuses upon the most important contributors to pneumonia
among vaccine preventable diseases, i.e. measles, pertussis, diphtheria and invasive
infections by Heamophilus influenzae type b and Streptococcus pneumoniae. High levels of
immunization against these agents are essential elements in the overall strategy of reducing
ARIs. These vaccines should be given within the Expanded Program on Immunization (EPI).7
Modification of risk factors – Programmes which can disseminate practical health education
messages related to prevention of risk factors should be developed. Depending on local
circumstances, messages should focus on the need to keep the child (especially the young
39
infant) dry and warm; to avoid exposure to tobacco smoke and cooking/ heating smoke, and
to continue feeding and giving fluids during the illness. 7
Identifying pneumonia by clinical signs and symptoms - The WHO has provided a
rationale for pneumonia case detection using clinical signs and symptoms without
auscultation or radiography: this forms the basis for empirical treatment of childhood
pneumonia. 7
REVIEW OF SIMILAR STUDIES; CAREGIVERS’ KNOWLEDGE, ATTITUDE
AND PRACTICE OF HOME MANAGEMENT OF ARIs
Acute respiratory infections (ARI) are a major cause of pediatric mortality and morbidity,
particularly when associated with delays in treatment. Farrow et al working in Ethiopia
observed that caregivers’ knowledge of appropriate home care for children with ARIs was
deficient.86 A study of mothers' knowledge, attitudes and practices regarding ARIs in their
children aged less than 5 years was conducted in an urban Ghanaian population. One hundred
and forty-three women who had at least one child aged less than five years were interviewed
in open air markets in Kumasi, Ghana. There was a poor maternal understanding of the
etiology of ARIs. Most respondents (73.4%) named exposure to cold as a direct cause of
cough. Many women incorrectly blamed worm infestation for causing cough and fever (21%)
and constipation for causing cough (25.9%). None mentioned pathogens as a cause of cough
and fever, and none said that good ventilation and avoidance of overcrowding prevent cough
and fever.87
The more serious the symptoms, the more likely the mothers were to seek treatment at a
health care facility (e.g., cough only, 0.7%; cough and fever, 6.3%; cough, fever, and
anorexia, 30%; and cough, fever, and lethargy, 57.3%). 87
40
Common home care practices for treating a runny nose included the use of ephedrine or other
types of nasal drops, herbal medicines, antipyretics, and antibiotics. Honey and cough syrup
were often used to treat cough and fever. Some herbal and home care therapies had
potentially harmful effects. For example, 25.9% said that they used castor oil as enemas to
prevent ARI and antibiotics were prescribed by 39.9% of the parents for treating coughs. 87
Similarly in some other studies reviewed, the concepts of infection or contagion were not
known. Chilling due to exposure to cold air or water was mentioned as the main cause of ARI
in studies conducted in Nigeria, 88 Indonesia, 89 Pakistan 91 Bangladesh 92 and Egypt. 93
Nigerian mothers also mentioned exposure to dust and smoke as a cause of ARIs. 88 Other
perceived causes of ARIs include poor hygiene, normal development, hereditary, 88 hormonal
imbalances, negligence by mothers, 94 and supernatural causes. 93
While the mothers exhibited an understanding of symptoms which differentiate between
mild and severe ARI, a substantial number indicated that they would delay accessing a health
care facility in the presence of the following symptoms which signify severe respiratory
distress: dyspnoea (11.2%); tachypnoea (18.9%); chest retraction (21.7%); cough, fever and
anorexia (30.0%); and cough, fever and lethargy (57.3%). 87
In most societies, mothers will know when their children have ARI. A study in rural
Bangladesh found that almost all mothers recognized pneumonia. 94 Reports also showed that
rural Ethiopian mothers could recognize pneumonia by grunting fast respiration and fever. 94,
95 Campbell and colleagues found that rural Gambian mothers were able to recognize ALRIs
as a severe disease. 96 They also could recognize that, ‘fast breathing’ and ‘difficult breathing’
were features which differentiated ALRIs from AURIs. Similar findings were reported in
India, Pakistan, Egypt, Guatemala, Bolivia and Mexico. 97 - 103
41
Other studies contrarily have shown that most mothers hardly recognize the signs and
symptoms of severe ARI notably ‘chest in drawing’ and ‘fast breathing’. Mothers in Ile-Ife,
Nigeria 104 could not generally recognize fast breathing and just like mothers in Ethiopia 105
and Myanmar.106
Beliefs and attitudes particularly influence how a family perceives and reacts to a child’s
illness, the health care and treatment options available to them and their decision about when
and where to seek help. Different societies have different local beliefs about causes,
symptoms and treatment of illness. For example, in a study of ARIs in the rural Gambia, fast
breathing was not viewed as serious enough when compared to cough, and was rarely used
as a motivation to seek care. Due to the perceived severity of ARIs, mothers often waited for
several days before taking their children to the health centre and usually after home remedies
and local healers had failed to offer relief. 107 In some other study, symptoms and signs such
as cough, fever and even convulsion were regarded by mothers as a normal part of a child’s
development and therefore did not seek outside care early. 104 Herman and colleagues also
reported that though Egyptian mothers generally recognized rapid or difficult breathing, they
did not use the recognition to take appropriate action.97 Charaly and Andina made similar
findings in Bolivia.103 Delay in care seeking due to misinterpretation of signs or
underestimation of severity of illness was also reported by other researchers in Guatemala, 99
urban Ethiopia 105 and Indonesia. 89
High levels of positive attitude were found among Indian mothers. Most of them (87.2%)
were worried about the adverse effects of ARIs and nearly 72% of them took early action
during ARI episodes. 100 A study by Kapoor and colleagues reported that a high percentage of
rural Indian mothers could recognize rapid and difficult breathing as indicative of severe ARI
and therefore are likely to seek immediate hospital care. 102 Some other study in rural
42
Bangladeshi reported that mothers could identify laboured breathing, chest retractions,
lethargy and inability to feed as signs of severe disease needing treatment outside the home.92
The choice of approach a caregiver will take in the treatment of ARI will depend on many
factors, some of which are traditional beliefs, level of education, income, perceived causes
and estimated severity of illness as well as accessibility of health care. The choices include
home care without drugs; home care after seeking the advice of a relative or neighbor; home
medication with purchased drugs or home treatment using traditional remedies; visiting a
traditional healer; seeking advice and/or prescribed treatment from a pharmacist; seeking
advice and/or prescribed treatment from a health worker in government or private practice. 108
A study on Nigerian mothers revealed that they often treated their children with traditional
herbal teas called “agbo” or other homemade remedies for cough. They occasionally bought
anti-pyretic and antibiotics from a pharmacy or local drug sellers. 88, 104 In rural Bangladesh,
mothers were reported to massage the chest with oils, avoid cold foods and seek spiritual
healing for ARI cases perceived to be caused by spiritual factors. 92, 94 Harmful traditional
practices were also reported among rural Mexican, Ethiopian, Indian and Ghanaian
mothers.87, 95, 98, 109 For example, the Mexican mothers applied tomato/potato paste to the
child’s throat as a form of treatment, while the Ghanaians used enemas as a preventive
measure.
HEALTH EDUCATION BEHAVIOUR MODELS AND THEORIES
Current models/theories that help to explain human behavior particularly as it relates to
health education, can be classified on the basis of being directed at the level of; a) Individual
(Intrapersonal); b) Interpersonal; or c) Community.
43
1) Health Belief Model
The Health Belief Model (HBM) is one of the first models which adapted theories from the
behavioral sciences to examine health problems. The HBM attempts to explain and predict
health behaviors by focusing on the attitudes and beliefs of individuals. The key variables of
the HBM are as follows. 122
Perceived Threat: This consists of two parts; perceived susceptibility and perceived severity
of a heath condition
Perceived Susceptibility: One’s subjective perception of the risk of contracting a health
condition
leaving it untreated (including evaluations of both medical and clinical consequences and
possible social consequences
Perceived Benefits: The believed effectiveness of strategies designed to reduce the threat of
illness
Perceived Barriers: The potential negative consequences that may result from taking
particular health actions, including physical, psychological, and financial demands
Cues to action: Events either, either bodily (e.g., physical symptoms of a health condition) or
environmental (e.g. media publicity) that motivate people to take action.
Other Variables: Diverse demographic, sociopsychological, and structural variables that
affect an individual’s perceptions and thus indirectly influence health-related behavior.
Self Efficacy: The belief in being able to successfully execute the behavior required to
produce the desired outcomes. 123
44
Implications of the HBM for Health Behaviors
HBM research has been used to explore a variety of health behaviors in diverse populations.
Such researches include influenza inoculations, Tay-Sachs carrier status screening, high
blood pressure screening, smoking cessation, seatbelt usage, exercise, nutrition, breast self-
examination and HIV/AIDs. 122
Limitations of the HBM
a) Most HBM-based research has incorporated only selected components of the HBM,
thereby not testing the model as a whole.
b) The HBM is a psychological model, and as such does not take into consideration other
factors such as environmental or economic factors, that may influence health behaviors.
c) The model does not incorporate the influence of social norms and peer influences on
people’s decisions regarding their health behaviors.
2) Stages of Change Model or Transtheoritical Model
The Stages of Change or Transtheoritical Model is based on behavior change being viewed as
a process and not an event, and that individuals are at various levels of motivation or
‘readiness’ to change. It is also based on the facts that since people are at different points in
this process; planned interventions should match their stage.125
There are six stages that have been identified in the model. They are;
i. Precontemplation – the person is unaware of the problem or has not thought
seriously about change;
ii. Contemplation - the person is seriously thinking about a change in the near future;
45
iii. Preparation – the person is planning to take action and is making final adjustments
before changing his behavior;
iv. Action – the person implements some specific action plan to overtly modify behavior
and surroundings;
v. Maintenance – the person continues with desirable actions (repeating the periodic
recommended steps while struggling to prevent lapses; and
vi. Termination – the person has zero temptation and the ability to resist relapse.
Implications of the Stages of Change Model or Transtheoritical Model
a) In relapse, the person reverts back to old behavior which can occur during either
action or maintenance stage.
b) The model is circular, rather than linear. The model is more of spiral as the
person may go through several cycles of contemplation, action, relapse (or
recycle) before either reaching termination or exiting the system without
becoming free of the addictive behavior
Limitations of stages of change Model:
a) As a psychological theory, the stages of change focuses on the individual without assessing
the role that structural and environmental issue may have on a person's ability to enact
behaviour change.
b) Since the stages of change presents a descriptive rather than a causative explanation of
behaviour, the relationship between stages is not always clear
c) Each of the stages may not be suitable for characterizing every population.
46
3) Consumer Information Processing Model
The Consumer Information Processing (CIP) Model is based on the premise that information
is a necessary tool in health education. However, just as knowledge is necessary but not
sufficient for behavior change, information is necessary but not sufficient for knowledge. By
understanding the key concepts and processes of CIP, health educators can examine why
people use or fail to use health information, and then design informational strategies that have
better chances for success. The CIP model considers that the information environment affects
how easily people obtain process and use information. This includes the amount, location,
format, readability, and ability to process relevant information.
There are two central assumptions of CIP; 126
a) Individuals are limited to how much information they can process and b) In order to
increase the usability of information, individuals combine little pieces or bits of information
into chunks and make decision rules to make choices faster and more easily.
Implications of the CIP model
a) Before people will use health information, it must be;
Available
Processable or in a friendly format.
b) It is necessary to choose the most important and useful points to communicate (either
verbally or in print) and place this information first and/or last in the presentation in order to
be remembered best.
c) The information should take little effort to obtain, draw the consumer’s attention and be
clear.
47
4) Theory of Reasoned Action (TRA)
The Theory of Reasoned Action is based on the assumption that most behaviors of social
relevance are under volition (willful) control. 124 In addition, a person’s intention to perform
(or not to perform) the behavior is the immediate determinant of that behavior. The goal is to
not only predict human behavior but also to understand it.
According to the TRA, a person’s intention to perform a specific behavior is a function of
two factors. 124
i. Attitude (positive or negative) towards the behavior – this is determined by the
person’s belief that a given outcome will occur if he/she performs the behavior and
by an evaluation of the outcome
ii. The influence of the social environment (general subjective norms) on the behavior –
this is determined by a person’s normative belief about what important or ‘significant’
others think he/she should do and by the individual’s motivation to comply with those
other people’s wishes or desires.
Implications of the Theory of Reasoned Action
a) Attitudes are a function of beliefs. If a person believes that performing a given
behavior will lead to on the whole positive outcomes, then he/she will hold a
favorable attitude towards performing that behavior. On the other hand, a person who
believes that performing the behavior will lead to mostly negative outcomes will hold
an unfavorable attitude. These beliefs that form the foundation of a person’s attitude
towards the behavior are referred to as behavioral beliefs. 124
b) Subjective norms are also a function of beliefs. These are the person’s beliefs that
certain individuals or groups think he/she should or should not perform a certain
behavior. If the person believes that most of these significant others think he/she
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should perform the behavior, the social pressure to perform it will increase and the
more he/she is motivated to comply with these others. If he/she believes that most of
this reference group is opposed to performing the behavior, his/her perception of the
social pressure not to perform the behavior will increase along with his/her motivation
to comply with these referents. The beliefs which underlie a person’s subjective
norms are termed normative beliefs. 124
Limitations of TRA:
Some limitations of the TRA include;
a) The inability of the theory, due to its individualistic approach, to consider the role of
environmental and structural issues and the linearity of the theory components
b) Individuals may first change their behaviour and then their beliefs/attitudes about it.
For example, studies on the impact of seatbelt laws in the United States revealed that
people often changed their negative attitudes about the use of seatbelts as they grew
accustomed to the new behavior.
5) Social Learning Theory or Social Cognitive Theory
In Social Learning Theory (SLT), human behavior is explained using a three-way
reciprocal theory in which personal factors (one’s cognitive processes), behavior, and
environmental influences continually interact in a process of reciprocal determinism or
reciprocal causality. These are very dynamic relationships where the person can shape
the environment as well as the environment shaping the person. Change is bi-
directional.127
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a) Reinforcement contributes to learning, but reinforcement along with an
individual’s expectations of the consequences of behavior determines the
behavior.127
b) Behavior is seen as a function of the subjective value of an outcome and the
subjective probability (or expectation) that a particular action will achieve that
outcome. The more highly valued the expected outcome, the more likely the
person will perform the needed behavior to yield the outcome. This type of
approach is referred to as ‘’value-expectancy theory.’’ 127
Interpersonal Health Behavior Theories
1) Social Networks/Social Support Theories.
Social networks can be referred to as kin (extended family) or non-kin (church, work groups,
friends, and neighbors who regularly socialize, clubs and sporting teams, while social
support refers to the varying types of aid that are given to members of a social network. 128
The social network/social support theory proposes that the social environment is important,
and advocates changes in the social ecology which may be supportive of individual change
leading to better health and a higher quality of life. However, within the community, long
term behavior change depends on the level of participation and ownership felt by those being
served.128
Research indicates that there are four kinds of supportive behaviors or acts that can be offered
to individuals within the social network. These are; 128
i. Emotional support – listening, showing trust and concern;
ii. Instrumental support – offering real aid in form of labor, money, time;
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iv. Appraisal support – affirming each other and giving feedback.
Limitation of Social Networks/ Social Support Theories
Not all network ties are supportive. ‘’Some or all ties may or may not be supportive’’.128
Community Level Models/Theories
1) Community Organization
Community organization has been formally defined as ‘’the method of intervention whereby
individuals, groups, and organizations engage in planned action to influence social
problems’’. There are three models of practice in Community Organization. 129
a) Locality Development – a very process-oriented model. Community change is sought
through participation of a broad cross-section of members in the community who attempt to
identify and solve their own problems. It stresses consensus, cooperation, building group
identity and a sense of community. Outside practitioners (coordinators or enablers ) help to
coordinate this effort and enable the community to successfully address its own concerns 129
b) Social Planning – stresses a technical aspect of problem solving with community
participation varying from much to little depending on the problem and the organization
variables present. It is more task-oriented, as expert planners use their technical abilities to
guide complex change processes. The design and implementation of social plans and policies
is the central focus of this model 129
c) Social Action – this is both task and process oriented. The model is used to increase the
problem-solving ability of the community and also to achieve some concrete changes in order
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to correct social injustice that has been identified by disadvantaged or oppressed group. Basic
changes are sought in major institutions or community practices. An attempt is made to
redistribute power, resources or decision-making in the community and/or to change basic
policies of formal organizations. 129
2) Diffusion of Innovations Theory
Diffusion of Innovations Theory provides an explanation for how new ideas, products and
social practices diffuse or spread within a society or from one society to another. Diffusion
can be thought of as a special type of communication in which messages are concerned about
a new idea. If a health education program is viewed as an innovation, this theory could
describe the pattern the target population would follow in adopting the program. 130
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BACKGROUND TO THE STUDY AREAS
Delta state is divided into three senatorial districts which are further divided into twenty five
local government areas. (LGAs) The senatorial districts are Delta South, Delta Central and
Delta North, and these have eight, eight and nine LGAs respectively. The Delta South people
are of three major ethnic groups, the “Itshekiris”, the “Isokos” and the “Ijaws”. The Delta
Central people are mainly “Urhobos”, while the Delta North people are majorly “Ibos”.
The study was carried out in two communities, in two different Local Government Areas
(LGAs) but in the same Senatorial district (Delta North) in Delta State with Issele-Azagba
community as the intervention and Ekwuoma community as the control groups respectively.
Intervention Site
Issele-Azagba, the intervention site, is one of the 18 communities in Aniocha North LGA in
the Delta North senatorial district of Delta state. The village is situated along “Lagos via
Benin to Asaba Federal Government express road” leading to Onitsha across the bridge
heading into Anambra State. Issele-Azagba has a territorial land area of 9 km2. It is bounded
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on the South by Ogwashi – Uku village, on the North by Akwukwu – Igbo village, on the
North-West by Issele – Uku village and on the South-East by Asaba town, the capital of
Delta state.
Issele-Azagba is made up of five major Quarters called “Ogbes” namely Ikem, Ogbe -
Onicha, Ogbe-Akpu, Abualo and Ogbe-Etiti. These major quarters are further divided into 17
subquaters (Clans) named according to families that have the same historical descent. Ikem
is divided into Umu Ojei-Agu, Idumu Iyase, Idumu Iso and Umu-Iba. In Ogbe-Onicha they
have Ogbe-Utu, Ogbe Ani, Iyada, Umu Ube and Idumu-Agu. Ogbe –Akpu is divided into
Idumu Odogwu, Idumu Ogbele and Idumu Ozoma. Ogbe –Etiti is divided into Akpoma,
Umu Ngbo, Umu Ajeboma and Okofia. Abualo as a quarter stands alone without further sub-
divisions. There were a total of 536 houses in Issele-Azagba village as at the time it was
counted (April 2010).
IsseIe-Azagba has an estimated total population of 7,238 people. The people are
predominantly farmers and traders selling farm produce. Majority are in the low/middle
socio–economic class, they are largely Christians and speak the Ibo language.
There is only one government owned health facility (A dispensary) in Issele-Azagba. It is
headed by a Nurse and assisted by two auxiliary nurses. Activities such as Immunization,
delivery services and treatment of common ailments take place in this dispensary. Cases
which cannot be managed at this level are referred to the nearest Primary Health Centre in a
neighbouring village which is about 15 kilometres away. There is one privately owned health
centre and four Patent Medicine Vendors/stores.
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Control site
Ekwuoma community, the control site is in “Ika North East” LGA also in Delta North
senatorial district of Delta state. It is bounded on the West-East by Umunede village, on the
South- East by Obior village and on the North-East by Igbodo village. Ekwuoma has four
major quarters namely Odopo, Umu Osi, Idumu Echem, and Idumu Ute. These four quarters
are divided into 13 subquaters.
As at the time counted (April 2010), total number of houses in Ekwuoma village was 577 and
estimated total population was 8,423. The people of Ekwuoma village are majorly farmers
and traders, and most belong to the low/medium socioeconomic class as well. They are
mainly Christians and speak the Ibo language. Ekwuoma has 6 private patent medicine stores
and a government health centre. The health centre offers mainly maternity and delivery
services and it is headed by a Midwife and four health assistants.
Both villages, Issele-Azagba and Ekwuoma are about 55 kilometres apart.
STUDY DESIGN
This is a Quasi–Experimental study designed to assess the effect of health education on
caregiver’s knowledge, attitude and practice of home management of ARIs in under-fives in
Issele-Azagba community in Delta state, using the caregivers of under-fives in Ekwuoma
community, also in Delta state as the controls.
Study population
The study population for the intervention group are the caregivers of children aged 0 – 59
months in Issele-Azagba community, Aniocha North LGA in Delta state while the study
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population for the control group are the caregivers of children aged 0 – 59 months in
Ekwuoma community, Ika Nor