Effect of an Educational Intervention among Rural Mothers Regarding Knowledge about Danger Signs in Children under-5 Years of Age

INTRODUCTION

Over the past 30 years, largely due to the efforts of respective governments and healthcare institutions, significant improvement has been noted globally in regard to child health and survival rates. In recent times, the fall in mortality numbers has increased. As such, out of every 27 children, one child is noted to die before reaching 5 years which during the 1990s was 1 death out of 11 children. Notwithstanding progress made in arresting the rate of under-5 child mortality, The World Health Organization (WHO) draws attention to the absence of universality of such progress. For example, till 2020 the Sub-Saharan African countries continued to witness the death of 74 children below the age of 5/1000 live births as compared to the global 37/1000. The WHO document notes that countries of this region, together with Central and South Asian countries, accounted for 80% of over 5 million under-5 child losing their lives in 2020. Notably, 53% of the global population hails from these countries. Yet, they witness most child deaths. The report called out India, Congo, Ethiopia, Pakistan, and Nigeria as the nations with notorious records of child mortality, making up for half of 2020’s mortality numbers.^1,2

In India, analysis of the National Family Heath Survey (NFHS-4), 2015–16 revealed wide variations in mortality rates of under-5 children between different districts. From the findings of the survey, scholars have interpreted that in relation to the 2030 target regarding under-5 child mortality outlined in the sustainable development goals (SDGs), India’s recorded mortality rate during 2015–16 was higher by 2 times.³ This implies that the rate of mortality of under-5 children in India was much higher than what should have been during the period covered by the survey.

In West Bengal, an analysis of NFHS-5 (2019–2020) shows under-five mortality rate has declined from 31.8 (NFHS–4) to 25.4, and it requires utmost care to reach the SDG target.

Principal causes of mortality are mostly preventable and are complications in preterm birth cases, pneumonia, malaria, asphyxia, diarrhea, and congenital problems. Children can be guarded from these diseases by providing adequate nutrition, vaccination for diseases, safe drinking water, and care by health service providers when required.⁴

As per Health in March 2018, West Bengal has new cases of Grade I Malnutrition about 16.72% among the age group (0–6).⁵ Mothers need to be made aware of this through cost-effective intervention.

The major goal of this intervention is to increase mothers’ awareness regarding danger signs in children under 5 years of age. Early detection of a child’s illness is a crucial step for the improvement of a child’s survival. Another major reason to carry out this research is to close the knowledge and comprehension gap between mothers and these danger signs.

The purpose of this study is to improve maternal awareness about danger signs in children under 5 years of age, underlining its probable significant impact in curbing incidences of under-five mortality from preventable causes.

MATERIAL AND METHODS

A quantitative approach with community-based intervention study design was conducted from February 2018 to January 2023 among the randomly selected 480 (240 in study and control arm each) women with under-5 children residing permanently under 48 sub-centers covering 134 villages in Hariharpur Block Primary Health Centre, district of South 24 Parganas, West Bengal which is also a field practice area of Rural Health Training Centre of Nil Ratan Sircar (NRS) Medical College, Kolkata. For the current study, 25% (12) of the sub-centers were chosen through simple random sampling. Randomization was done using the “randomization by pair” method. Names of all 12 sub-centers (SCs) were written on separate papers, two drawn each time blindly, and a coin toss, determined allocation: Heads to the study arm and rest to the control arm. This was repeated to allocate all the 12 SCs into two arms. Forty mothers from each sub-center were selected through simple random sampling. Mothers who have under-5 children, living there continuously for 1 year, know Bengali, and are willing to participate were included and those who were ill or pregnant at the time of data collection were excluded.

Data were collected through structured interviews conducted at the household level using a pre-designed and pre-tested semi-structured questionnaire containing information pertaining to demographic and socioeconomic variables and knowledge of mothers regarding danger signs in children under 5 years of age.

The prepared tool and criteria checklist were tested by nine experts to establish the validity of the tool. The experts were asked to consider additions, omissions, and suggestions to improve the clarity of items. The content validity ratio was compiled as on experts’ opinions. The reliability was obtained by the test-retest method. The structured teaching material was administered to 10 mothers in the community. It was found that items were clear and the time needed to complete the interview schedule is 40–50 min.

The final draft of the structured teaching program was prepared after incorporating the suggestions and opinions of the experts.

The study was conducted with approval from the Ethics Committee of NRS Medical College and Hospital (Memo No. NMC/8161 dated December 27, 2017) and voluntary written consent from participants.

RESULTS

During 3^rd intervention/assessment, 8 participants from the study arm and 5 from the control arm were absent/dropped out. The total dropout rate was 2.70%.

The analyses revealed that the participants belonging to both arms were comparable in terms of religion (Hindu vs. Muslim), type of family (Nuclear vs. Joint), socioeconomic status; current age (year), age at marriage (<18 vs. ≥18 years), parity, no. of under-5 children and breastfeeding practice; and education and occupation of them and their husbands. There was no statistically significant difference between arms about the number of ante-natal (AN), post-natal (PN) visits, AN visits paid at home, place of delivery, and information/messages received before and after delivery regarding exclusive breastfeeding, family planning, and immunization of baby. They were also found to be alike as far as their knowledge of the danger signs [Tables 1 and 2].

Effect of educational intervention

It is clear that the intervention has a demonstrable role in increasing the knowledge of the mothers [Table 3]. Now, to make the outcome of the intervention evident, it is required to find out whether the same assessment encounter as well as ongoing routine information education and communication process has some impact on the knowledge of the mothers belonging to both the groups.

Table 3: Distribution of knowledge scores between arms at different levels of assessment, n=480.

Level	Arm	n	Median		Ranks	Test statistics
				Mean rank	Sum of ranks	Mann–Whitney U	P-values
Level 0	Study	240	5	238.70	57288.50	28368.500	0.772
	Control	240	5	242.30	58151.550
Level 1	Study	240	8	334.92	80381.00	6139.000	<0.001*
	Control	240	5	146.08	35059.00
Level 2	Study	240	11	360.25	86460.50	59.500	<0.001*
	Control	240	5	120.75	18979.50
Level 3	Study	232#	11	351.50	81548.00	0.000	<0.001*
	Control	235#	6	118.00	27730.00

#13 Mothers did not turn up during 3^rd intervention/assessment, *Significant

Analysis using Friedman test considering knowledge score of study arm showed that it has increased significantly across the levels but it has also found to be increased paradoxically at some of the levels of assessment in the control arm [Table 4].

Table 4: Distribution of knowledge score within Study Arm at different levels of assessment (n=232^#).

Arms	Levels				Descriptive statistics			df	P-value
		n	Mean	Median	Standard deviation	Mean rank	χ2 test
Study	Level 0	232	5.1121	5	1.35334	1.02	628.26	3	<0.001*
	Level 1	232	7.7931	8	1.40511	2.03
	Level 2	232	11.0302	11	1.18210	3.42
	Level 3	232	11.2629	11	0.68047	3.53
Control	Level 0	235	5.1447	5	1.51500	2.36	115.48		<0.001*
	Level 1	235	5.1362	5	1.49020	2.34
	Level 2	235	5.1319	5	1.50627	2.33
	Level 3	235	5.4766	6	1.19225	2.96

# Eight and five mothers in study and control arms were absent during 3^rd intervention, so all those were excluded in analysis of Friedman test, df: Degrees of freedom, *Significant

Pairwise comparison of Friedman test indicated that the knowledge score of study arm was found to be increased significantly at all levels of assessments compared to that of baseline score as well as previous level. However, knowledge score at level 3 did not show significant increase over that of level-2 [Figure 1].

Close

Figure 1:

Distribution of test statistics at different levels of assessment in Study arm, n = 232. Sig = Significant

Export to PPT

Further analysis indicated that the knowledge score of control arm was also found to be increased significantly at level-3 assessment compared to other levels of assessment [Figure 2].

Close

Figure 2:

Distribution of test statistics at different levels of assessment in control arm, n = 235. Sig=Significant

Export to PPT

DISCUSSION

Due to the scarcity of a similar study, the sociodemographic characteristics of the participants considered in the current study were compared with the general population of West Bengal as well as with district South 24 Parganas as per NFHS-5 data 2019–2020. As there was no study found on under-5 danger signs, all comparisons were made with neonatal danger signs which are a fraction of under-5.

The present study showed that 45% of mothers from both the study and control arm were married before the age of 18 years which is quite similar to the general population of West Bengal (48%) and South 24 Parganas (42%).⁶

Furthermore, the present study showed that 59% of mothers from both arms had visited the antenatal clinic (ANC) 4 times or more, which is quite lower than West Bengal (74%) and South 24 Parganas (86%). Regarding the place of delivery, the present study showed that 90% baby delivered in the institution, which reflects almost the same as in West Bengal (92%) and South 24 Parganas (91%).

The present study also revealed that out of total births, 10% are still delivered in the home and that’s almost the same as in West Bengal (8%) and South 24 Parganas (9%). In the case of breastfeeding immediately after birth, it was found from the present study that above 68% of mothers have breastfed their babies within 1 h after birth which is much higher in West Bengal (59%) and South 24 Parganas (46%).⁶

One study done in China⁷ shows 75% of mothers visited ANC more than 4 times, 97.3% delivered a child in a health institution, 83% of mothers did at least one postnatal visit, none were educated about neonatal danger signs, and it is quite similar to present study where >50% mothers from both arms have visited ANC above 4 times, above 90% mothers have got institutional care at the time of delivery of their children, only 20% mothers from both arms have visited the post-natal clinic, and none of the mothers from either arm were aware of neonatal danger signs.

All over the world, the stakeholders are working together to achieve SDG 3, which aims to reduce preventable death among all. For children under 5 years of age and particularly for neonates, prompt action is needed after proper recognition of danger signs for the reduction of preventable death. A few main causes of under-5 death are pneumonia, diarrhea, and malaria (2019) which are preventable. Reduction of morbidity and mortality from those diseases requires immediate recognition of danger signs and prompt action.

The present study shows at baseline (41.7%) of mothers of the study arm and (47.5%) of mothers of the control arm were not aware of the term “danger signs” in children under 5 years of age. None of the mothers from either arm were able to identify “lethargy,” “coldness of body,” “anemia” and “infection” as dangerous signs which is consistent with the report of Challa and Krosuri in India,⁸ Choi et al., in Bangladesh,⁹ and Merga and Alemayehu in Ethiopia.¹⁰

A community-based cross-sectional study conducted in Mollasimla village of Hooghly district of West Bengal concluded that acute illnesses are still largely prevalent in the rural community. Mothers are the first caregivers and need to be made aware of the preventive measures and the need to seek proper treatment at the earliest.¹¹

CONCLUSION

It is evident from the study results that there was a huge gap between the expected and existing knowledge levels regarding the danger signs among mothers of under-5 children. It is also noteworthy that significant improvement in knowledge about the danger signs could be possible through an effective educational intervention which is quite possible during AN/PN checkups/visits by the community health workers (CHW). Hence, a feasible strategy for utilizing the CHWs may be contemplated for increasing the knowledge of women regarding danger signs among under-5 children during routine AN/PN check-ups/visits which must be made universal.