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HEALTH CARE SEEKING BEHAVIOURS OF MOTHER HAVING UNDER 24 MONTHS OLD CHILD ATTENDING OUTPATIENT DEPARTMENT OF TRIBHUVAN UNIVERSITY TEACHING HOSPITAL, KATHMANDU

Health care seeking behaviour of a mother has an important role in reducing morbidity and mortality related common childhood illness amongst under-five children. The main objective of this study was to identify the health care seeking behaviour of mothers who attended tertiary level hospital in Kathmandu for common childhood illness. The study was conducted in the paediatrics out-patient department of Tribhuvan University Teaching Hospital Kathmandu by employing a descriptive design under the quantitative research approach. Similarly, a non-probability convenience sampling technique was used in the study in which 151 mothers having 0-24 months (0-2 years old) children attending in OPD were included. Prior to data collection, written approval of the proposal was obtained from Research Department and Institutional Review Board, Institute of Medicine and Director of TUTH. The data were collected with the help of interview schedule and analyzed by using descriptive statistics. Result of this study found that 85.4% mothers had information regarding common childhood illness. All respondents were found seeking care when their children got sick. Out of the total respondents, 90% of them took their children in health facility whereas remaining 10% took their children to the traditional healer for treatment. Out of the total respondents taking their children in health facility, 80.8% mentioned that the children’s condition was worsened and, among them 65.4% preferred government health facility. Reason for not taking to health facilities were far distance, expensive treatment, lack of money, lack of faith and mothers’ perception of severity of illness. From this study, it can be concluded that the service provided through government health facilities needs to be improved and focus should be given on health education to mother regarding common childhood illness and its severity. Likewise, it is also necessary to increase mothers’ positive attitude and perception toward medical treatment when a child gets sick.


INTRODUCTION
Globally, despite a significant progress has been made in reducing mortality in children under five years of age, about 6.9 million children of under five years died in 2011. 1 Pneumonia and diarrhoea are leading killers of the world's youngest children, accounting for 29 percent of deaths among children under 5 years of age worldwide. Nearly 90 percent of deaths due to pneumonia and diarrhoea occur in Sub-Saharan Africa and South Asia. 2 Nepal is one of the poorest countries in the world. The total population of the country is 26494502, out of which 2984000 are of under age of five years. 3 In Nepal, even though there is significant decrease in infant and child mortality from year 1990 to 2010, still large numbers of children are suffering from diarrhoea and respiratory problems and ranked as major killer health problems in the country. Acute diarrhoeal diseases (ADD) and ARI (Acute Respiratory tract Infections) are most important causes of morbidity and mortality among the children in Nepal as well. 4 Improving families' care seeking behaviour could contribute significantly to reduce child mortality in developing countries. Seeking prompt and appropriate care could reduce child deaths due to acute respiratory infections by 20%. 5 Various studies from developing countries have reported that delay in seeking appropriate care and not seeking any care contributes to the large number of child's deaths and existing interventions could prevent many deaths among children if they are presented for appropriate and timely care. 6 Study on changing poor mother's care seeking behaviours in response to childhood illness in Nicaragua 7 reported that more than 75 % of the mothers involved in the study selected public health facilities as their first choice when they face a childhood illness. This is because of low consultations cost and regular community visits by government health staff. Similar scenario is seen in Nepal where out of total cases, 72% of ARI cases were treated by female community health volunteers in community level. 7 Prevalence of childhood illness and mothers' care seeking behaviour in Ethiopia showed that out of 415 mothers, 72.7 % sought treatment from health care facilities for sick children. Those mothers who were not seeking medical care from health care facilities, 53.3% mentioned that illness was not serious, 26.7% lack of money and 13.3% did not seek any benefits from such childhood illness. 8 In recent years, epidemiologist and social scientists have focused their study toward health seeking behaviour associated with the two leading causes of child mortality, namely diarrhoea and ARI .Yet, the information about how and when families in developing countries seek treatment for these prevalent illness remains seriously incomplete. 9 So far very less study found investigating health care seeking behaviours for common childhood illness among mothers in Nepal which has significant role in reducing under five morbidity and mortality associated with common childhood illness especially ARI and Diarrhoea. Therefore, this study was carried out on health care seeking behaviour of mothers having under 24 months old child attending in OPD so as to find out their care seeking behaviours.

METHODS
Ethical approval was taken from Research Department, and Institutional Review Board, Institute of Medicine and Director of TUTH. This descriptive cross-sectional study was designed to find out the mothers' health care seeking behaviour having under 24 months old child attending Paediatric Out Patient Department (OPD) of Tribhuvan University Teaching Tribhuvan (TUTH), Kathmandu January 2016-April 2016. A non-probability convenience sampling method was used to select mothers attending the OPD (bringing their child for health check up). One hundred fifty-one mothers who had at least one (0-24 month's old) child and who had suffered from diarrhoea, fever, cough and cold during the previous 1month period of data collection were included in the study. Responses were collected through face to face semi-structured interviews. The semistructured questionnaires were developed based on the research objectives. Developed semi-structured questionnaires guide was divided into two parts: Part I: It included personal data of mothers (age, ethnicity, religion, education, occupation, number of under five children), household characteristics (type of family, income of family, amily size, main source of income) and information related to child's birth order, age, place of birth and immunization status etc. s Part II: It included questions related to mothers' awareness and perception toward common childhood illness including their source of information, symptoms of sickness, causes, danger signs, availability and accessibility of health services and perception regarding severity of child's illness, mother's health care-seeking behaviours for their children's illness such as diarrhoea, fever, cough and cold at present and past episodes. Behaviours were: sought medical care, did not seek medical care (drug vendor, traditional healer, faith healer, self treatment and no action).
Data were collected from 2016 January to 2016 April. Data were checked, organized, reviewed, and coded daily for its completeness, consistency and accuracy. Data were entered in SPSS 19 Software Package and analysis was done using simple descriptive statistics and presented in table.

RESULTS
The results of responses are displayed under individual question asked from the participants:   Others (excessive cry, abdominal distension 14 9.3 Don't know 3 1.9 *= Multiple responses of water, (9.3%) mosquito bite and worm infestation and some others lack of care such as foods and water problems, lack of immunity and climate changes. Even in this era, few mothers believe evil power being the cause of common childhood illness. Table 3 shows that 46.4% mothers perceived their child's illness as severe one. In contrast, only 5.29 % of mothers said they didn't know the severity of their child's illness. Regarding the understanding of severity of symptoms that need immediate treatment, two third of the respondents (i.e.68.9%) indicated to high fever or fever persisting more than 24 hours, 59.65% to breathing problems, 56.3% to diarrhoea, 51.7% to convulsion, 49.7% to unconsciousness, 44.4% to vomiting, 23.2% to blood in stool and poor drinking respectively. Whereas, remaining 1.9% said that they don't know.  Table 4 shows that all respondents sought treatment while a child got sick. Out of the total respondents, 90.0% said they took their child to health facility when she/he became sick and remaining 9.93% took their children to the traditional healer for treatment. While giving reason for visiting health facility, 80.8% respondents viewed to be the worsening health condition of their child. In contrast, a very few 2.2% said that reason for visiting health facility was for prevention of further complications. Majority of children 63.23% were taken to government health facility whereas a few of them (17.6%) were taken to private health facility to seek care. Likewise, nearly two-thirds (72.8%) of children were taken to health facility after 24 hours of onset of illness.  Table 5 demonstrates that among the mother respondents who didn't visit health facility, 33.3% said that reason for not seeking health facility for treatment was long distance from health facilities followed by 26.6% expensive treatment and lack of family support, 20% disease not severe, 13.3% lack of money and long waiting hours and remaining 6.6% lack of faith and accessibility of service respectively. Among the respondents who took their children to traditional healers, 86% mentioned that it was due to the family pressure, other 80% said that it was due to their faith on traditional healers, whereas 66.6% felt that the treatment was cheaper and easily available. In contrast, remaining 13.3% said that the reason were others than those mentioned above.

DISCUSSION
This study found that majority of respondents (85.4%) had information about common childhood illness. Among them 48.0% respondents had obtained information from health workers, 44.9% obtained from previous experience and only 16.3% had gained information from friends.
In response to causes of common childhood illness, majority of the respondents (i.e.90.1%) viewed bad weather (cold /catarrh) to be the cause of common childhood illness whereas 76.2% viewed to be dirty environment, 44.4% viewed to teething 33.1% viewed to god' or evil, 27.8% viewed to be witchcraft, 19.9% viewed to the lack of immunization,16.6% viewed to organism, 13.2% to absence of water, 9.3% to mosquito bite and worm infestation and others viewed it to be the lack of care , foods and water problems, lack of immunity and climate changes respectively. From the findings presented above, it can be inferred that mothers still have ingrained belief on evil power that can cause common childhood illness which is not true.
Drawing from the perception of respondents toward childhood illness, it is found that 46.4% respondents perceived their child illness as severe one. But, in contrast, a study conducted in Ethiopia among 612 mothers on health care seeking behaviours for childhood illness had found that less number of mothers' perceived illness was not serious and not taken for treatment. 8 Likewise, regarding the perception about danger signs and symptoms of common childhood illness need immediate treatment, this study showed that more than 2/3 rd (68.9%) of respondents perceived that high fever or fever that persists more than 24 hours as danger signs and symptoms that need immediate treatment followed by 59.65% breathing problems. Nearly similar result was reported on the study conducted by Sreeramareddy et al. 2006 10 in which fever, difficulty in breathing and drinking poorly were mentioned as danger signs of common childhood illness.
A study conducted in Yemen in 2013 on factor affecting health seeking behaviour for common childhood illness among 212 mothers reported that 51.42% respondents sought medical care during their child sickness. 11 But study conducted in Ethiopia showed that out of 415 mothers, 72.7% sought treatment from health care facilities for sick children. 8 In this study, findings showed that 100% respondents sought treatment while child got sick, of which 90.0% took their child to health facility or sought medical care when she/he was sick. Out of them who sought medical care, 63.23% preferred government health facility. Nearly similar result was reported by a study conducted in Nicaragua where 75% mothers sought treatment from public health facility. 7 In search of the reason for not seeking health facility or not seeking medical treatment, this study found that out of 151 respondents, 15 of them did not take their child to health facility during illness. Of which, 33.3% said that the reason behind not seeking health facility or not seeking medical care for treatment was long distance from health facilities followed by (26.6%) expensive treatment and lack of family support, (20%) disease not severe, (13.3%) lack of money, lack of faith on service respectively. Similar results were reported in a study conducted in Ethiopia, where far distance from facilities, lack of money, illness was not serious and lack of faith were respectively found as factors for not seeking health facility (Ethopia). 8 Likewise, Webair & Bingouth (2013) also reported that perception toward severity of illness, symptoms, and lack of faith on medical treatment were affecting to seek medical care. 11 From this it can be concluded that far distance from health facilities, perception toward severity of illness, lack of money, lack of family support and faith on services appear to be the factors affecting for health care seeking behaviour of mothers. Among the mothers who took their children to traditional healer during child illness, 86% mentioned that family pressure followed by 80% faith on traditional healer, 66.6% felt treatment was cheaper and easily available.

CONCLUSION
Mother's health care seeking behaviour has a vital role to reduce under five deaths caused by common childhood illness especially acute respiratory infection, fever and diarrhoea in developing countries including Nepal. From the findings of this study, it can be concluded that the mother's awareness on symptoms, causes and danger signs about common childhood illness was good but not enough because the responses on different options were less except few options. This study results also concluded that reported almost all mother used to seek care while child get sick. Of which, few mothers still seek care from traditional healer as first choice of treatment. Regarding factors affecting care seeking behaviour of mothers were far distance of health facilities, lack of money, perception toward severity of illness and lack of family support, expensive treatment and lack of faith on treatment provided by health facility. Study also found that mothers who used to take their child to health facilities during common illness preferred government health facilities. So, health worker should focus toward educating mothers on different aspects of common childhood illness during their visit with their child.
On the basis of study result it can be recommended that government health facilities should focused their programme toward educating mothers about common childhood illness which can prevent major part of under five deaths due to common illness.