Understanding motivations and patterns of care-seeking and adherence to medical treatments for paediatric pneumonia in Nigeria

Background: Nigeria has the highest number of childhood pneumonia deaths worldwide, and it is not on track to meet the sustainable development goal 3.2. Despite the availability of proven interventions to prevent pneumonia deaths, uptake and quality implementation have been lacking and inequitably distributed. It is therefore important to understand the motivations around care seeking and treatment adherence behaviours for paediatric pneumonia in Nigeria.

Methods: Five sub-studies (I-V) were conducted at different times across Lagos and Jigawa states in Nigeria, which have different sociocultural and health- related characteristics. Sub-study I was a household survey conducted in Jigawa (December 2019-March 2020) to assess pneumonia knowledge and care seeking behaviour for under five children with pneumonia symptoms. Sub-study II was a qualitative study conducted in both states among caregivers and community members to understand pneumonia perception and care seeking experiences during the quest for therapy for children with pneumonia symptoms. In sub-studies III and IV, we conducted interviews with healthcare providers and caregivers. We had group discussions with community members to understand and explore motivations and barriers shaping antibiotic adherence (sub-study III) and medical oxygen acceptance (sub-study IV). In sub-study III, we assessed antibiotic adherence levels from a repeat household survey. Between December 2020 and March 2021, we conducted in-depth interviews with caregivers and healthcare providers in Lagos to understand care seeking practices during the COVID-19 pandemic (sub-study V).

Results: In sub-study I, 1,661 eligible women with 2,828 children under five were recruited. Caregiver's knowledge of pneumonia was low, as just 4.9% of the women could name both cough and fast/difficulty in breathing as pneumonia symptoms; 1% correctly reported all four transmission risks for pneumonia (breathing dust, poor hygiene, being near someone sick, being near someone coughing); 36.4% and 4.2% answered antibiotics and oxygen therapy as a treatment for pneumonia respectively. Of the 2828 children sampled, 536 (19.0) had symptoms of acute respiratory illness (ARI) in the prior two weeks, and 341/536 (63.6%) were considered sick and less than half were taken to a healthcare provider for care (161/341, 47.2%). In total, 240 children (8.5%) presented to a healthcare provider in the preceding 2 weeks; of these, 72% had pneumonia-specific symptoms. Primary health centres (PHCs) and private patent medicine vendors (PPMVs) were the most common sources of care outside the home. Maternal knowledge was not associated with care seeking, but care seeking was higher among children with fever compared to those without fever(aOR:2:45 [95% CI: 1.38-4.34]) whose mothers first married when they were older - aged 20-35 years compared to those whose mother married at younger age (AOR: 5.15 [95% CI: 1.38-19.26]), and children from the wealthiest homes compared to those from household with less income (AOR: 2:13 [95% CI: 1.03- 4.38]).

In sub-study II, we found evidence of a gendered role in care seeking behaviours, with female caregivers saddled with the responsibility of child's care and illness recognition while the husband provides financial resources. However, participants did not mention preferential care seeking behaviours for male and female children. Some participants perceived traditional medicine to be better than modern medicine. Care experience included self-medication with cough medicine or attendance at PPMV for a cocktail of medicine or presentation at primary health facilities or hospitals if previous care was unsuccessful.

In sub-study III, 645/9994 children aged 2-59 months had ARI symptoms in the prior two weeks, 71.5% (461/645) were taken for care, and 41.2% (190/461) were prescribed antibiotics. Of these, 42 (21.9%) and 18 (9.4%) were prescribed dispersible amoxicillin (amoxicillin DT) and amoxicillin tablets respectively-the recommended treatment for pneumonia. The median duration of antibiotic use was five days (range:1-14 days). Overall, 98/190 (51.6%) had good antibiotic adherence. Reasons for non-adherence were caregiver's carelessness and nonchalant attitude towards antibiotic use, child struggling with caregivers, and the lack of adequate information from providers.

From interview data in sub-study IV, we found that oxygen therapy was a source of financial and emotional distress to caregivers. Acceptance of medical oxygen treatment was a sense-making process characterised by a perceived sense of urgency, trust in healthcare, and a feeling of hopelessness especially in Jigawa state. Knowledge of medical oxygen was limited, causing rumours and misconceptions to shape caregivers' perceptions of medical oxygen treatment. While these were modifiable, cost was a major barrier to oxygen acceptance in Lagos.

In sub-study V, we found the COVID-19 pandemic affected care-seeking behaviour for children, as health facilities were considered high risk, and there was fear of a COVID-19 diagnosis. Aside from hospital avoidance, care was delayed or sought from alternative sources. Lack of transportation and diminished household income contributed indirectly to low care-seeking from hospitals.

Conclusion: Individual, family, and community factors strongly influenced care- seeking and adherence to therapy for children with pneumonia in Nigeria, revealing opportunities to improve care and outcomes for this priority population. Pneumonia knowledge was low among caregivers and was not associated with care seeking behaviour. Children with pneumonia were taken for care from multiple sources, notably PHCs and PPMVs. Motivation to seek care is influenced by social and systemic barriers, notably household dynamics, illness perception, financial considerations and perceived health system responsiveness. Oxygen hesitancy exists and can be modified but the underlying causes vary with context. Caregivers require more support to improve adherence to antibiotics.

List of scientific papers

I. Bakare AA, King C, Salako J, Bakare D, Uchendu OC, Burgess RA, Shittu F, Juliano A, Isah A, Ahmed T, Ahmar S, Valentine P, Olowookere TF, McCollum ED, Colbourn T, Falade AG, Graham HR. Pneumonia knowledge and care seeking behavior for children under-five years in Jigawa, Northwest Nigeria: a cross-sectional study. Front Public Health. 2023;11:1198225. https://doi.org/10.3389/fpubh.2023.1198225

II. Bakare AA, Graham H, Agwai IC, Shittu F, King C, Colbourn T, Iuliano A, Aranda Z, McCollum ED, Isah A, Bahiru S, Valentine P, Falade AG, Burgess RA, Consortium IP. Community and caregivers' perceptions of pneumonia and care-seeking experiences in Nigeria: A qualitative study. Pediatr Pulmonol. 2020;55 Suppl 1:S104-S12. https://doi.org/10.1002/ppul.24620

III. Bakare AA, Stagg HR, Salako J, Bakare D, Colbourn T, Graham HR, Falade AG, King C. Understanding adherence to antibiotic prescription among caregivers of children with pneumonia symptoms in Jigawa state: a mixed-method study. [manuscript]

IV. Bakare AA, Salako J, King C, Olojede OE, Bakare D, Olasupo O, Burgess R, Mccollum ED, Colbourn T, Falade AG, Molsted-Alvesson H, Graham HR. 'Let him die in peace': understanding caregiver's refusal of medical oxygen treatment for children in Nigeria. BMJ Global Health. 2024;9(5):e014902. https://doi.org/10.1136/bmjgh-2023-014902

V. Bakare AA, Olojede OE, King C, Graham H, Uchendu O, Colbourn T, Falade AG, Alvesson HM. Care seeking for under-five children and vaccine perceptions during the first two waves of the COVID-19 pandemic in Lagos State, Nigeria: a qualitative exploratory study. BMJ open. 2023;13(3):e069294. https://doi.org/10.1136/bmjopen-2022-069294