European Journal of Cardiovascular Medicine

“A healthy child is a sure future” is one of the themes of WHO. Childhood is one such vulnerable period wherein growth and development occur in various dimensions and needs special attention and care. Young children fall an easy prey to infectious diseases.

Globally every year around 10.5 million children die before reaching their fifth birthday that is about 30,000 children every day! Most of these deaths occur in developing and underdeveloped countries. The five most important causes of under-five mortalities are ARI (19% of total deaths in under-fives), diarrhoea (17%), malaria (8%), measles (4%), HIV/AIDS (3%), neonatal conditions (37%) and injuries (3%).1 The world health Report (1999) estimated that 27 per cent of Disability Adjusted Life Years (DALYS) attributable to major childhood conditions are due to acute respiratory tract infections. 2.

Acute respiratory tract infections are the most common cause of illness and death among children in the world.  Children all over the world suffer from frequent coughs and cold, but in developing countries these are often associated with life threatening pneumonia, which is the leading cause of death among under-five children.3 The risk factors of acute respiratory tract infections can be grouped into two categories, namely host and environment. Host factors comprise of malnutrition, immunization status, vitamin A deficiency, absence of breast-feeding, low birth weight and young age. Environmental factors include indoor air pollution, poor hygiene and sanitation, overcrowded housing, low socio-economic status and parental smoking. 4. Two problems are encountered with respect to the case management which is inappropriate antibiotic use and mother or parents not aware of the correct home care. 5

Majority of the ARI episodes are self-limiting. However, pneumonia is a serious life-threatening illness with high case fatality rates, unless treatment is started early. This is generally not well understood by the parents and episodes of cough and cold among children are taken as usual occurrences which will be cured with time. Sometimes parents remain busy in their routine activities and tend to postpone taking the child to the health worker or a doctor. This results in serious consequences because the time between onset of pneumonia in a young infant and development of complications and death may be as little as 2 – 3 days. Majority of the cases of pneumonia do not need in-patient care and can be treated at home. Even children who may be hospitalized have to be taken care of by the mothers at home after discharge. The mother plays a key role in the treatment of the child with cough and cold. It is therefore very important that the mother understands the basic principles of home treatment. As a part of treatment of a child it is the duty of health workers and treating physicians to advise mothers on management at home.

Acute Respiratory Infection (ARI) is sometimes mild but causes fatal conditions. Due to the mother’s traditional practices and beliefs, she is unable to recognize danger signs and symptoms of ARI. So the mother needs the education about taking care of an ARI child and management of ARI children to prevent complications. 6

The overall awareness among mothers with regard to their rights, duties, of responsibility would strengthen the health care services in the society, and mothers should be educated on prevention, promotive and curative aspects of acute respiratory infections. Since mothers can make anything possible, provides they should be educated. Mother has to play a key role in the treatment of the child with cough and cold and pneumonia, as they do not require any hospitalization and are totally preventable and curable. Home health care has been growing in importance as a component of the health care delivery system, since many children who have conditions that required hospitalization a few years ago are now being cared for at home. Hence the following study was conducted to assess the effectiveness of information, education and communication on knowledge and practices of mothers of under five children regarding acute respiratory infections in Mallasandra rural field practice area of VIMS &RC.

OBJECTIVES

1)           To assess the knowledge and practices among mothers of under five children regarding prevention and control of ARI in rural field practice area of VIMS & RC at Mallasandra PHC.

2)           To provide Information, Education and Communication (IEC) to the above mothers of under five children regarding prevention and control of ARI.

3)           To assess the effectiveness of IEC on these mothers every quarterly during 6 months period of post intervention.

An Interventional study was conducted in the rural field practice area of VIMS & RC, Bengaluru between March 2013 to March 2014. Assuming 15% improvement in the knowledge and practices in mothers of children under five and 1%worsening in their practices based on a previously published study, Sample size calculated is 211. Assuming 10% drop out rate, Final Sample size calculated is 211+21=232 METHODOLOGY: METHODOLOGY: A total of 231 children under 5 enrolled in all 4 Anganwadis (Day care centres) of rural field practice area of VIMS & RC were included in the study and their mothers were approached. Consent was taken from mothers of all under-5 children prior to the study and were interviewed through pre-tested semi structured questionnaires. IEC was given to the mothers on the prevention and control of ARI disease in under five children through focal group discussions and interpersonal communication such as Practice of exclusive breast feeding, Initiation of complementary feeding after 6 months of age, Continuation of breastfeeding up to 2 years of age, Complete immunization of the child. Mothers were also educated about ARI as a disease, its causes, its signs and symptoms and how to identify warning signs and when to take the child to the health facility. AV aids were used in the form of demonstration, posters, charts and PowerPoint presentations. Participatory communication through interactive sessions on prevention and control of ARI diseases in under five children were given priority with distribution of leaflets. Information education communication was given in the form of interpersonal communication and focal group discussions. Follow up was done for 1 year with every 3months IEC and an assessment was made every 3 months through post-test questionnaires. Statistical analysis: Data obtained was coded and entered into Microsoft excel worksheet. This was analyzed using SPSS version 21. Statistical analysis was done based on Chi-square test to find out the association between ARI and the variables. McNemar’s test was used to find out any change in knowledge and practice after the IEC. The questionnaire was divided into four sections, the first section on mother’s knowledge on risk factors of ARI, the second on mother’s knowledge on danger signs of ARI, the third section on mother’s practices of proper home management and fourth section on mother’s health care seeking attitude and utilization consisting of various questions. A maximum score of 30 could be attained based on the best fit scenario. Score Range for the knowledge and practice level categorization Knowledge and Practice level Score Range Poor 0 – 15 Good 16 - 30 The following scores were used to measure the knowledge and practices level of the mothers regarding ARI and its management. The scoring was used for classification of mothers by knowledge and practice level. The scoring was also used to measure the improvement of the knowledge and practices of the mothers before and after intervention

The present study was an interventional study taking into consideration the various major risk factors responsible for ARI in children under 5. The mother’s Knowledge, attitude and practices regarding these risk factors and identification and management of ARI in their children were assessed and discussed below.

The occurrence of ARI among children who were breastfed less than 6 months, exclusively up to 6 months and beyond 6 months were compared and found to be 178 (95.7%) of 186, 18 (64.3%) of 28 and 12 (66.7%) of 18 children respectively.

Table 1: Acute Respiratory Infections in children under five according to Exclusive breastfeeding

This difference of duration of breast feeding was highly significant statistically (χ2 = 37.01, p < 0.0001) with occurrence of ARI among children

Table 2: Acute Respiratory Infections in children under five according to Prelacteal feeds

Among 126 children who were given pre lacteal feeds 121 (96%) had developed ARI and among those who were not given pre lacteal feeds 87 children (82.1%) of 106 did not develop ARI respectively. This difference in practice of pre lacteal feeds had highly significant association statistically (p = 0.0011) with occurrence of ARI in children.

Table 3: Acute Respiratory Infections in children under five according to time of initiation of breastfeeding

The occurrence of ARI among 128 children who were not breastfed within 1 hour from the time of birth was seen among 123 (96.1%) children and among 108 who were breastfed within 1 hour from the time of birth were 85 (81.7%) respectively. This difference in timing of initiation of breastfeeding was highly significant statistically (p = 0.0008) with the occurrence of ARI.

Table 4: Acute Respiratory Infections in children under five according to time of initiation of supplementary feeding (Weaning)

There was an increase in occurrence of ARI episodes among 201 children who were initiated supplementary feeding before 6 months compared to 14 children who were initiated at 6 months and the 17 children beyond 6 months which was 190 (94.5%), 6 (42.9%) and 12 (70.6%) respectively. The recommended appropriate time of weaning was found to be strongly associated with the occurrence of ARI (highly significant p < 0.0001). A study by Hajheeboy N. et al showed that early initiation of breast feeding was found to be protective against ARI and there were very few episodes of ARI who were fed within one hour (p<0.05), the study also showed administration of prelacteal feeds was related to higher prevalence of ARI, the association was found highly significant (p<0.001)⁷  

Table 5: Acute Respiratory Infections in children under five according to birth weight

In the present study, the occurrence of ARI among children with low birth weight was higher with 74 (97.4%) of 76 LBW children suffering with recurrent episodes of ARI  compared to the children with normal birth weight 134 (85.9%) of 156. This difference was highly significant statistically (p = 0.007). A cross-sectional study Prajapathi et al among 500 children in urban and rural areas of Ahmedabad revealed occurrence and severity of ARI was high in LBW compared to normal weight. This difference was highly significant (chi square = 21.30, p < 0.001) in accordance with this study.⁸

Table 6: Acute Respiratory Infections in children under five according to immunization status

In the present study, the occurrence of ARI among children with immunization status incomplete for age was higher: 40 (100%) compared to the children who were immunized: 168 (87.5%). This difference was significant statistically. A study by Smita MN et al in rural setting of Pune district showed that incomplete immunization was significantly associated with higher incidences of ARI(p<0.05) which goes well along with this study.⁹

There was increase in the occurrence of ARI among children in homes where biomass fuels were used compared to homes using only. This difference in usage of various fuels with the occurrence of ARI was highly significant statistically (p < 0.0001). A study by Hemagiri K et al conducted-on association between type of cooking fuel and ARI showed that the Use of biomass fuels for cooking was found to be significant risk factor (p=0.001) with an odds of 2.49.¹⁰

Table 7: Acute Respiratory Infections in children under five according to type of fuel used in home

Table 8: Acute Respiratory Infections in children under five according to ventilation in house

The occurrence of ARI was high among children in homes where ventilation was inadequate with 110 (98.2%) of 112 children developing ARI  compared to homes with adequate ventilation where 98 (81.7%) of 120 children developing ARI. This factor of ventilation was highly significant in the association with ARI statistically. Savitha MR et al (2005) also in their study showed, that lack of adequate ventilation (natural ventilation i.e. houses with windows) was a significant environmental risk factor causing ARI in children (very significant, p<0.001). 32.7% of ALRI cases did not have any windows in their house as compared to 4.8% of controls.¹¹

The mother’s knowledge, attitude and practices regarding ARI prevention and management contributing to recurrence and arise of complications of ARI were also explored and studied. Regarding mothers’ hygienic practices preventing transmission of ARI, 112 mothers did not follow any of the hygiene practices  leading to the increased transmission and recurrencesof ARI among 107(95.5%) of children of these mothers.  This factor was highly significant statistically compared to those who washed hands and followed seasonal precautions. This factor was highly significant statistically (p = 0.0063). The under 5 children mothers practices of proper home management of ARI were also explored and it was found that, A small proportion of mothers, 45 (19.4%) followed all practices as per proper home management of mild ARI, Larger proportion about 128 (55.2%) followed few practices; 59 (25.4%) did not follow any of the practices as recommended. This was significantly associated (p = 0.0174) with the recurrence and worsening of ARI episodes

In the present study, only 80 mothers (34.5%) utilized the recommended registered medical facilities and 21 (9.1%) contacted health workers ,  with 38 mothers (16.4%) utilized Indigenous clinics, 35 mothers (15.1%) preferred traditional healers and 30 mothers (12.9%) approached pharmacists. 28 of mothers did not opt for any health services due to lack of health seeking behavior. This difference in utilization of health services was significant statistically in the recurrence and worsening of ARI episodes. The mothers practice of timing to seek health care services during ARI were studied and was found that, only 42 (18.1%) of mothers immediately utilized the health services. Larger proportion 108 (46.6%) gave no importance to the timing of seeking health services and 54 (23.3%) utilized the health services after deterioration of the health condition while 28 (12.1%)  of mothers did not utilize any of the health services, thus neglecting the time factor. This difference to seek and utilize the health services in a timely manner was found to be non-significant statistically for recurrence of ARI.

In the initial assessment, 55% of the mothers had good knowledge and practice levels and 45% had poor knowledge and practice levels. After the intervention in the first quarterly assessment, knowledge and practice levels improved with 60% of  mothers with better knowledge and practice levels . In the second quarterly assessment, it further improved with 64% of mothers having good knowledge and practice levels. There was a dropout in the number of mothers participating in the intervention program during the second quarter. Education programme was continued and the mothers were encouraged to adopt and continue the best practices as recommended in the handbook provided.

Table 9 : Knowledge and practice level of mothers of children under five during initial, first and second quarterly assessment

Table 10: Comparison of initial and first quarterly assessment of mother's knowledge and practice level

Mc-Nemar’s test was applied to find out the significance of improvement of knowledge and practice levels of mothers of children under five during initial, first and second quarterly assessment. During initial assessment out of 232 mothers of children under five 128 mothers (55%) had good knowledge and practices regarding management of ARI; 104 (45%) had poor knowledge and practices regarding management of ARI. During the first quarterly assessment, the mothers with poor knowledge reduced to 93 (40%), indicating 11 mothers showed an improvement in the knowledge and practice levels. This difference was highly significant statistically (p = 0.000977).

Table 11: Comparison of initial and second quarterly assessment of mother's knowledge and practice level

During the second quarterly assessment 6 mothers were lost to follow-up. The mothers with poor knowledge reduced to 81 (36%). Compared to the initial assessment this improvement was highly significant statistically (p < 0.000001).

Table 12: Comparison of first and second quarterly assessment of mother's knowledge and practice level

During the first quarterly assessment 133 (59%) mothers had good knowledge and practice levels and 93 (41%) had poor knowledge and practice levels. (6 mothers who lost their follow-up during second quarterly were not considered here). During second quarterly out of 226 children’s mothers, 145 (64%) had good knowledge and practice levels while 81 (36%) had poor knowledge and practice levels. This difference was highly significant statistically (p = 0.000488).

A study by Gunay O et al was conducted to assess the effectiveness of health education on the prevalence of ARI of the children among the mothers in Hacilar, district of Kayseri. Mothers of 57 children for the control group and 69 children for the interventional group were selected by convenient sampling. The intervention involved 30 minutes of face-to-face education of mothers regarding ARI prevention and treatment. The results of the study showed that prevalence of ARI decreased from 49.3% to 27.5% in the intervention group and from 43.9% to 38.6% in the control group. Significant difference in the interventional group indicated the effectiveness of health education.¹²

A study by Campbell H et al was conducted to assess mothers’ perceptions towards childhood ARI in selected areas of Gambia, West Africa. A total at 25, 046 interviews were recorded over a period of one year with mother from three villages and four hamlets. Mothers recognized acute lower respiratory tract infections as a severe disease and recognized fast and difficult breathing as symptoms, which discriminated it from upper respiratory infections. The study showed that even in poorly educated populations in which traditional practices are widespread, it may be possible to educate mothers to identify lower respiratory infections and to seek early treatment.¹³

A study was conducted in 8 communes of 4 districts of Vietnam involving 1,216 mothers and 1,231 fathers of children under 5 where only 4 communes had implemented the IEC activities for mothers' groups. Overall, mothers who participated in the IEC mothers' groups were better informed about ARI, 86% of mothers knew that fast breathing is a sign of pneumonia compared to 56% in other areas. 28% of mothers did not treat a cough or cold with antibiotics as the first home treatment while 10% of the control group did not. Significant difference was seen in management of ARI after IEC ¹⁴

The present study was an interventional study conducted in villages in Mallasandra Primary Health Centre, rural field practice area of Vydehi Institute of Medical Sciences and Research Centre. The study period was from January 2013 – September 2013. The objective was to assess the knowledge and practices among mothers of under five children regarding prevention and control of acute respiratory infections, to provide Information, Education and Communication (IEC) to the above mothers of under five children regarding prevention and control of ARI and to assess the effectiveness of IEC in these mothers every quarterly during six months period of post intervention.

Study was conducted among 232 mothers of children under five. During follow-up in the post interventional period, 6 (2.6%) mothers were lost to follow-up due to migration. One-to-one interview was conducted to collect information about the modifiable risk factors and health care seeking attitude regarding management of ARI and health service utilization of the mothers after taking consent. Clinical examination and anthropometry were conducted on the under five children and IEC was given to the mothers.

In the present study a very large proportion of children under five, nearly 90% of the children had a history of acute respiratory infection. In the present study faulty feeding practices were observed in this area. A large proportion was given prelacteal feeds and not breastfed within one hour of birth. Majority of the children were not exclusively breast fed for 6 months. Weaning (i.e. supplementary feeding) was initiated before 6 months in majority of the children. Biomass fuels were more commonly used fuel for cooking or heating (67.7%). Majority of the houses had inadequate ventilation (48.3%). Smoking beedis or cigarettes was seen in sufficient number of houses (22.4%). All these factors were adequate enough for a rise in indoor air pollution.

In the study among 232 mothers of children under five regarding knowledge of ARI And management, 6 mothers (2.6%) did not have knowledge of the mild signs of ARI. 98 mothers (42.2%) were unaware of the danger signs of ARI. 112 mothers (48.3%) did not follow any hygienic practices to prevent transmission of ARI. 59(25.4%) of mothers did not follow any practices as per proper home management of mild ARI. Regarding utilization of health services 48 (20.7%) were negative about seeking health services. 103 (44.4%) did not utilize the recommended health services but used alternate health services. 28 (12.1%) did not opt for any health services due to lack of health seeking behavior. 108 (46.6%) of mothers gave no importance to the timing of seeking health services.

During initial assessment, 55% of the mothers of children under five had good knowledge and practice levels. After intervention the knowledge and practice levels improved to 60% and 64% of the mothers respectively in the first and second quarterly review. This difference was significant statistically.

The factors showing highly significant association in occurrence of ARI were faulty feeding practices, indoor air pollution, immunization status and Vitamin A supplementation. Malnutrition and anaemic status, poor hygienic practices, improper home management and the type of health service used were the other factors found to be significant.

This shows that through an effective IEC the knowledge, attitude and practices of the mother on ARI can be improved. Through interpersonal communication, as done in this study, mothers in this study were made aware of how to prevent this disease by adopting simple and healthy practices .

LIMITATIONS OF THE STUDY

1. Methods normally employed for investigation of ARI are clinical examination, blood investigation, imaging, histopathology and microbiologic investigation, and invasive techniques. However, in the present study only clinical examination and anthropometry were measured.
2. There was a drop out of roughly 3 %in the study due to migration and non-compliance and it was not possible to trace those mothers. However this did not affect the study significantly.
3. There were no control groups taken in the study to conclude that the observed improvement in knowledge and practices regarding ARI and its prevention was only because of the educational intervention
4. The scoring pattern should have been into 3 grades each with points of 10 each of Low, Moderate and Good, as mere difference of 1 would categorize borderline score into poor or good thus affecting the efficiency of intervention.

RECOMMENDATIONS

• The mothers should be trained and educated to recognize danger signs of ARI and to seek a doctor, recognize mild signs and proper home management by Health workers (ASHA, AWW) on regular home visit or Anganwadi visit
• Knowledge regarding ARI and its risk factors can be imparted n to mothers as early as during ANC checkups, post-natal visits, during immunization visits for the child as well as to other family members.
• Distribution of colourful brochure in local language illustrating ARI symptoms and appropriate prevention measures in the health centres