Pneumonia-related Ideations, Care-seeking, and Treatment Behaviors among Children under 2 Years with Pneumonia Symptoms in Northwestern Nigeria

"Ideational metrics can provide important program‐relevant insights and should be further explored for other health areas."

Timely care-seeking and treatment for paediatric pneumonia is a cornerstone of child survival programmes but remains a challenge in Nigeria and other high-mortality countries. The reasons for the delay or refusal to seek advice or treatment for a sick child are complex and multifaceted. Among them are psychosocial influences ("ideations") that could directly influence the pathway to care, such as caregiver beliefs, values, perceived risks, or social norms. Models such as the Ideation Model of Strategic Communication and Behavior Change theorise that these ideations are intermediate determinants that help catalyse a person's decision to engage in a specific action. This paper aimed to develop a set of pneumonia-related ideational factors and to examine the extent of their associations with care-seeking for children under 2 years with pneumonia symptoms in northwestern Nigeria.

The two-stage cluster-sample cross-sectional population-based survey was conducted in Kebbi, Sokoto, and the Zamfara States in wards targeted for a United States Agency for International Development (USAID)-funded social and behaviour change (SBC) programme. This SBC programme aims to deliver integrated messaging across malaria, family planning, and maternal, newborn, and child health and nutrition (MNCH + N) in Sokoto and Kebbi States and malaria-only SBC messaging in Zamfara State. The present study used the baseline survey, which was conducted before SBC programme implementation. Fieldwork was conducted over a 4-week period in September 2019.

The ideational domains considered in the study included pneumonia knowledge, perceived disease severity, perceived susceptibility, and self-efficacy (general ideations), as well as perceived treatment efficacy, subjective care-seeking norms, attitudes toward health services, and participation in household decision-making about child health issues (treatment ideations). Sociodemographic variables were also included in the model based on empirical evidence of their relationship with child health treatment practices in Nigeria and other low-income countries.

A total of 3,043 women with a completed pregnancy in the past 2 years resulting in a live birth responded to questions about their last-born children. Among these children, 350 had had pneumonia symptoms in the 2 weeks before the survey interview; of them, 33.8% (95% confidence interval (CI): 26.4-42.1) were taken to formal medical care, and 38.0% (95% CI: 28.2-48.2) were given antibiotics to treat the condition.

Key findings:

• Caregivers who reported that antibiotics were an effective treatment for pneumonia (treatment efficacy) were 35% more likely to seek care from a formal medical source for pneumonia symptoms than those who did not (1.35, 95% confidence interval (CI): 1.00-1.82; P = .050). In a similar veing=, caregivers who agreed that health facilities frequently had medicines needed to treat sick children (health services perceptions) were more than twice as likely to seek formal medical care for pneumonia symptoms as those who disagreed (2.13, 95% CI: 1.35-3.35; P = .001).
• On the other hand, caregivers who believed that most women in their communities would visit drug shops (defined here as an informal source) before visiting health facilities for sick children (social norms) were 29% less likely to seek formal medical care for paediatric pneumonia symptoms (0.71, 95% CI: 0.52-0.97; P = .030).
• The significant ideational domains for predicting antibiotic treatment for paediatric pneumonia symptoms were maternal beliefs about treatment efficacy and illness susceptibility (e.g., women who viewed only weak children as dying from pneumonia were 29% less likely to give antibiotics). Antibiotic treatment was also associated with sociodemographic variables including household wealth and maternal education.

In conclusion: "Taken together, current findings suggest that SBC messaging that focuses on improving pneumonia knowledge alone may not be sufficient to raise pediatric pneumonia care-seeking and treatment rates in northwestern Nigeria or elsewhere. Instead, program interventions must also address perceived and actual health services quality, help shape social norms related to care-seeking for sick children and reinforce caregiver beliefs about treatment efficacy and illness severity and susceptibility."