Background: Early health seeking behavior is important in reducing the morbidity and mortality caused by acute diarrheal illnesses among under-five children. But children who get acute diarrhea and seek no early health care the different determinants are exposed to the leading causes of increased under- five mortality in developing countries, including Ethiopia. The purpose of this study was to assess the prevalence and associated factors of early health seeking behavior for childhood acute diarrheal illnesses in Gondar town, northwest Ethiopia.

Method: An institution-based cross-sectional study was conducted on 367mothers/ caretakers at Gondar town government health centers from March 25 to May 8, 2016. Descriptive statistics, bi-variable and multivariable regression analyses were performed. P-values less than 0.05 and 95% Confidence Interval (CI) were used to determine the association between independent and dependent variables.

Results: A total of 367 participants were enrolled, of whom only 4 (1.1%) failed to respond. The majority of the respondents, 338 (93.1%), were mothers. The prevalence of early health seeking behavior was 22.6% with (95% CI: 18.5-27.3). Perceived need factors, such as clinical conditions of symptoms, mild Adjusted Odds Ratio [AOR=2.62; 95% CI: (1.02-6.70)], health system factors of previous service use of less than one hour [AOR=2.15; 95% CI: (1.13- 4.10)], and enabling factors, like giving Oral Rehydration Solution (ORS)/and breast feeding [AOR=0.38; 95% CI: (0.19-0.78)] were statistically associated with EHSB.

Conclusion: The prevalence of early health seeking behavior for childhood acute diarrheal illness in this study was low compared to the national 2011 EDHS reports. Perceived mild illness status, previous waiting time for health service, and giving ORS / breastfeeding were factors significantly associated with early health seeking behavior. Supporting mothers/caretakers who arrive early at health institutions having perceived mild conditions of children’s diarrheal illness, increasing the motivation of health providers to serve efficiently and quickly are essential. We strongly recommended that mothers/ caretakers who give ORS/ and breast feed at home during diarrheal illness and seek institutional care be encouraged by providing lessons on the local media.

Mothers/caretakers, early health seeking behavior, under-five children, acute diarrheal illness, Gondar town, Ethiopia

Early health seeking behavior (EHSB) includes the activities of mothers/caretakers’ during childhood diarrheal illnesses. It is important to take immediate and accurate measures against childhood diarrheal illnesses. The roles of mothers/care takers are essential in early health seeking behavior since the majority of childhood illnesses and deaths relate to low level of mothers/care takers responses [1-3].

Diarrhea is the second major cause of childhood mortality all over the world. Globally,760,000 and in African regions 500,000 children die every year due to diarrheal illness without ever reaching health facilities owing to mothers/care taker slack of early health seeking behavior [4-7].

Although Ethiopia has already achieved the Millennium Development Goal (MDG4), under- five mortality rates due to diarrheal illness has been13%, however, early care seeking interventions have the potential to reduce such mortalities [2,8,9].

The perception of mothers/caretakers with regard to EHSB is important in providing Oral Rehydration Therapy (ORT) and nutritional support to prevent dehydration, electrolyte imbalance and hypoglycemia which causes death [10,11]. Increasing the recognition of mothers/caretakers’ and using resources for health services can reduce diarrheal disease mortality. But mothers/caretakers’ inability to identify the early signs of dehydration and loss of excessive volume of fluid through prolonged diarrheal illness increases the probability of child death [12,13]. Different studies showed that the determinant factors for mothers/caretakers’EHSB for childhood diarrheal illnesses were cultures, beliefs, socio-demographic distinctions, women’s autonomy, economic conditions, physical and financial accessibility, disease pattern, and health service issues [14]. Reports of the World Health Organization (WHO) and others indicator that appropriate health seeking behavior and proper care reduce child death and childhood illness by 20% [15]. But the prevalence of EHSB of mothers /care takers ‘in different localities of Ethiopia was not well-understood. And achieving the Sustainable Development Goals (SDG)by reducing under-five mortality by 2030 calls for evidence-based interventions [16]. Identifying the prevalence and associated factors of EHSB is very important for the implementation of child health intervention programs, general assessment of resource requirements, and intervention prioritization. Therefore, this study assessed the prevalence and associated factors of early health seeking behavior for childhood acute diarrheal illnesses in Gondar town, northwest Ethiopia.

An institution-based cross-sectional study was conducted at Gondar town health centers of the Amphora Regional State, North West Ethiopia. Gondar town is located 738 km from Addis Ababa, the capital of Ethiopia. Administratively, the town has two districts, 12 sub-cities, and 21 kibbles (smallest administrative units). The overall climatic condition of the town is favorable. According to the Central Statistical Agency(CAS) of Ethiopia, the total population of the town was 333,432, 173,206 women, 160,226 men, and 45,146 under five children [17].

The following assumptions were considered: ‘‘N” was the required sample size’s” was a standard score corresponding to 95% confidence level; “D” was marginal error of 5%; “P” =32 %, the proportion of mother’s EHSB for acute diarrhea was taken from the Ethiopian Demographic and Health Survey of 2011 (EDHS)[8].

adding a 10% allowance for non-response was taken. 334+ 33= n= 367 which was the final sample size; 367 mothers/care takers with under- five children with acute diarrhea were taken as a sample in all health centers. The systematic sampling technique was employed to select mothers/caretakers from each health center. The first mother/ caretaker after the fourth interval was selected by the systematic sampling method. Interviews were made with the first mother/ caretaker and continued with every fourth mother/care taker. But when the selected mothers/caretakers didn’t fulfill the inclusion criteria, the next mother/caretaker was interviewed.

Dependent variable was early health seeking behaviors of mothers/care takers

Independent variables were socio demographic characteristics of mothers/ care takers and children. Perceived need factors, the severity and symptom types perceived by mother/care takers; such as mild, moderate and severe. The others are health service characteristics and enabling factors.

Perceived severity: mothers/caretakers were asked about the current health status of children, that is, the magnitude of the child’s illness in terms of severity, moderateness or mildness [21].

Licensed care providers: A practitioner with formal medical education and a degree from a recognized institution.

Modern care: care sought from qualified medical professionals in government health facilities and private hospitals/clinics.

Complimentary care: types of care such as purchasing medicines from pharmacies, using home remedies, and visiting traditional healers.

Unlicensed health care providers: included traditional healers or practitioners without any formal qualification.

Under-five Children: children from 0-59 months.

A total of 367 participants were enrolled, of whom only 4 (1.1%) failed to respond. The majority of the respondents, 338 (93.1%), were mothers. The mean age of the mothers/ caretakers was 27.9 (SD ± 7.3) years. Less than 30%, 105 (28.9%), of the mothers/ caretakers completed secondary school; more than half, 204 (56.2%), of the mothers/ caretakers were housewives; 195 (53.7%) of the children were male; the median and inter-quartile age ranges (IQR) of the children were 19 and 21 months. The majority of the children, 313 (86.2%), lived in families with less than five members and 159 (43.8%) of the diarrheal cases occurred between 24-59 months of age (Table 1).

Nearly 45%, 162 (44.6%)of the mothers/caretakers earned monthly income of ETB601-2000. The majority of the respondents, 305(84%), were comfortable with the service fees. Of the cases, 144 (39.7%) were given fluid during their diarrheal illnesses (Table 2).

Most of the respondents, 325 (89.5%), said that the journey from home to health centers took less than an hour. Nearly 60%, 211 (58.9%), obtained services in separate under-five clinics and 100 (27%) were Rota virus vaccinated (Table 3). Of the respondents, 163 (44.9%), 165 (45.5%) and 35 (9.6%) perceived child illnesses as severe, moderate and mild, respectively; 244 (67.2%), 237 (65.3%), 171 (47.1%), and118 (32.5%) were aware of symptoms, such as dehydration, vomiting, fever, lethargy, and inability to drink or breastfeed, respectively (Table 4). Of the participants, 80 (22.6%) reported to health facilities on the first day, while 45 (12.4%), 96 (26.4%), 42 (11.6%), 25 (6.9%) and 73 (20%) after two, three, four, five, and more than six days, respectively. 

The prevalence of early health seeking behaviors noted in this study was 22.6% (95% CI: 18.5-27.3) (Figure 1).

Mothers /caretakers who perceived mild health status of children were 2.62 times more early health seekers than those who perceived severe symptoms [AOR=2.62; 95% CI: (1.02-6.70)].Mothers / caretakers who waited for less than one hour during previous services were 2.15 times early health seekers than those who waited for greater than one hour [AOR=2.15; 95% CI: (1.13-4.10)]. Mothers/ caretakers who gave ORS / breast milk were 62% less likely to be early health seekers than those who did not give ORS / breast milk [AOR=0.38; 95% CI: (0.19 - 0.78)] (Table 5).

Table 1: Socio demographic characteristic of early health seeking behavior of childhood acute Ddarrheal illness at Governmental health centers in Gondar Town, Northwest Ethiopia, 2016 (N=363).

*ETB-Ethiopian birr
Table 2: Enabling factors of early health seeking behavior of child hood acute diarrheal illness at Governmental health centers in Gondar Town, Northwest Ethiopia, 2016 (N=363).

Illnessat Governmental Health Centers in Gondar Town, northwest Ethiopia, 2016(N=363).
Table 3: Health system factors of early health seeking behavior of child hood acute diarrheal

Table 4: The severity and symptom type perceive by mother/care takers of early health seeking behavior of child hood acute diarrheal illness at governmental health centers in Gondar town, northwest Ethiopia, 2016 (n=363).

Figure 1: The prevalence of early health seeking behavior of child hood acute diarrheal illness at Governmental health centers in Gondar town, northwest Ethiopia, 2016.(n=363).

In this study, the prevalence of early health seeking behavior of childhood acute diarrheal illnesses was 22.6% (95% CI: 18.5-27.3), which is in line with those of studies done in Ethiopia [22], Nigeria [1], and Bangladesh [23].The possible explanation may be that most mothers /caretakers in developing countries have no culture of using health services early due to low health awareness, and since diarrhea is related to the manipulation of teeth eruption and thought to be not a killer. This finding is comparatively high compared to those of studies done in Ethiopia [24], and Dhaka and Bangladesh [13]. This might be because mothers/caretakers have different health seeking practices, like going to traditional healers and going shopping for drugs. This finding is lower than those of studies conducted in the urban slums of Kolkata, India [18], Pakistan [25] and Niger [26]. This might be due to the development of health infrastructure, sociodemographic variations, cultural differences, and the extent of access to health information of mothers/caretakers who seek early health care. Our finding is also lower than those of studies conducted in Ethiopia [8,22,27]. These national studies used pooled data, large sample size, and included both urban and rural areas, while ours focused on urban settlements only. That is why the finding of the national study was higher than the result of this one.

Increased perceptions of mothers/caretakers about EHSB and decrease morbidities and mortalities of under- five children by promoting family health and national growth. In this study, mothers/ care takers of under-five children with acute diarrheal illnesses and waited for less than one hour for previous services, sought health 2.15 times earlier than those who waited for previous services for longer than one hour. This is supported by studies conducted in Nigeria [1] and South Africa [27]. Long waiting time for services can affect the perceptions of early health seeking behavior of mothers / caretakers and leads to delays and child health deteriorates to the extent of being unable to respond to any medical management.

In this study, the occurrence of early health seeking 2.62 times higher among mothers /caretakers who perceived children as having mild health status compared to mothers /care takers who perceived severe health status. This is supported by studies done in Kenya [28], Africa, Asia [29] and Dhaka, Bangladesh [13]. Mothers/caretakers who perceived diarrheal illness as mild clinical conditions of children on the first day were earlier health seekers than mothers/caretakers who took longer than 24 hours to notice problems. Such delays lead to the deterioration of conditions because diarrhea is frequent loose or watery bowel movement that alters the child’s normal pattern to severe condition as the duration extends.

In this study, mothers/caretakers who gave ORS/and breastfed at home were 62% less likely to be early health seekers than those who did not give. This is in line with the result of studies done in Kenya [28] and Pakistan [25]. The possible explanation is that providing home antibiotics and fluids decreases mothers/caretakers early health care seeking outside the home. This is because mothers/caretakers think that breastfed children are well and can recover at home by taking only ORS without further assessments by health providers.

This study was not triangulated, and the paucity of similar literature on early care seeking behaviors of mothers/care takers relating to childhood diarrheal illness has limited the discussion. 

Overall, early health seeking behaviors of mothers/caregivers of under-five children with acute diarrhea was low (22.6%) compared to the national EDHS 2011 report. Perceived mild illness status, previous waiting time and giving ORS/and breastfeeding were factors significantly associated with EHSB. Encouraging mothers/ caretakers to go to health institution son the first day of illness or when conditions of children are mild and increasing the motivation of health providers to give health services efficiently and quickly to alleviate the problem are suggested. Encouraging mothers/ caretakers who give ORS/ and breastfeed at home during diarrheal illness to seek institutional health care and providing information on the media to enhance early health seeking behavior are strongly recommended. 

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