Diare dan Pneumonia.pdf

Determinants of Care Seeking for Children WithPneumonia and Diarrhea in Guatemala: Implicationsfor Intervention StrategiesNigel Bruce, PhD, Daniel Pope, PhD, Byron Arana, MD, Christopher Shiels, MPhil, Carolina Romero, Lic, Robert Klein, PhD, and Debbi Stanistreet, PhD

Globally, some 7.6 million children youngerthan 5 years die annually, the majority fromlow-income countries.1 Two of the mostimportant causes are acute lower respiratoryinfections, mainly pneumonia and diarrhea(18% and 14% of all deaths in childrenyounger than 5 years, respectively). Ade-quate access to health care for young chil-dren with pneumonia and diarrhea is ex-tremely important in improving survival asthere are cheap and effective interventionsavailable. In 2003, the Bellagio Child Sur-vival Study group reviewed child survivalinterventions feasible for delivery in low-income settings, and concluded that if ef-fective interventions had global coverage,63% of childhood deaths could be pre-vented.2 The power of existing interventionsis not matched by the capacity of healthsystems to deliver them to those in greatestneed in a comprehensive way and on anadequate scale.3 This situation persists, anda recent study of global research prioritiesfor the prevention of deaths from pneumo-nia among children by 2015 identified bar-riers to care seeking and access as one of thehighest priorities.4

In Guatemala, the 2006 infant mortalityrate was 31 per 1000 live births, and under-5mortality was 41 per 1000 child-years.5 Inrural areas where the majority of the popula-tion resides, the infant mortality rate andunder-5 mortality rates are likely considerablyhigher. On the basis of their investigation,Heuveline and Goldman suggested that im-proved access to health care could haveconsiderable impact on under-5 mortality inGuatemala.6 Studies conducted in the 1990sfound that health care uptake was very poor,with between 60% and 80% of families notseeking any formal, qualified health carefor acute lower respiratory infections and

diarrhea.6,7 In relation to poor uptake, povertywas seen as an important predictor, andeducation and ethnicity were found to be lessimportant.8

In addition to informal health care in Gua-temala (traditional healers, midwives, neigh-bors, local stores, pharmacies), formal servicesare provided by the Ministry of Public Healthand Social Assistance (MSPAS). The mainhealth facilities include health posts (usuallystaffed by an auxiliary nurse), health centers(staffed by at least 1 doctor and qualifiednurse), and “national” (general) and specializedhospitals. Recently there has been substantialgrowth in private services (individual doctorsand hospitals), stimulated by rising income inurban areas and dissatisfaction with publicservices. Other health services are provided bythe Social Security Institute and nongovern-mental organizations. From 1997, MSPAS hasalso funded the Programme to Extend Cover-age of Basic Health Services (Extension de

Cobertura [EdC]). This program, part of thewider Comprehensive Health Care System(Sistema Integrado Atencion de Salud), involvesthe contracting of nongovernmental orga-nizations to extend basic services to impover-ished rural populations.9

Following a randomized controlled trialinvestigating the impact of reducing householdair pollution on pneumonia among children,10

and motivated by efforts to develop inte-gration of protection, prevention, and treat-ment,11 we carried out a study in the samecommunities of Comitancillo and San Lorenzointo barriers to health care access. We usedmixed methods (population-based surveys andqualitative interviews and focus groups) tounderstand the key demand and supply-sideissues that could inform future interventionsto improve access to high-quality care. Wereport here results from the survey component,and focus on the determinants of formal careseeking for maternal report of an episode in

Objectives. We identified barriers to care seeking for pneumonia and diarrhea

among rural Guatemalan children.

Methods. A population-based survey was conducted twice from 2008 to 2009

among 1605 households with children younger than 5 years. A 14-day calendar

recorded episodes of carer-reported pneumonia (n = 364) and diarrhea (n = 481),

and formal (health services, public, private) and informal (neighbors, traditional,

local shops, pharmacies) care seeking.

Results. Formal care was sought for nearly half of severe pneumonias but only

for 27% within 2 days of onset, with 31% and 18%, respectively, for severe

diarrhea. In multivariable analysis, factors independently associated with formal

care seeking were knowing the Community Emergency Plan, mother’s percep-

tion of illness severity, recognition of World Health Organization danger signs,

distance from the health center, and having someone to care for family in an

emergency.

Conclusions. Proximal factors associated with recognizing need for care were

important in determining formal care, and were strongly linked to social

determinants. In addition to specific action by the health system with an

enhanced community health worker role, a systems approach can help ensure

barriers are addressed among poorer and more remote homes. (Am J Public

Health. 2014;104:647–657. doi:10.2105/AJPH.2013.301658)

RESEARCH AND PRACTICE

April 2014, Vol 104, No. 4 | American Journal of Public Health Bruce et al. | Peer Reviewed | Research and Practice | 647

children of pneumonia, diarrhea, or both in thepast 14 days, with “formal” care defined ascontact with 1 or more MSPAS, private, or EdCservices.

METHODS

The study communities were 2 municipali-ties within the rural western highlands ofGuatemala in the Department (regional ad-ministrative area) of San Marcos. San Lorenzois 35 kilometers from the town of San Marcos(the departmental main town, about 45 min-utes by road), and Comitancillo is 30 kilome-ters farther north. Both areas are poor, relyingmainly on subsistence farming. San Lorenzo,however, is somewhat more developed andaffluent, with a higher proportion of Ladinopeople who are more acculturated to theSpanish-speaking culture. According to the2006 survey, Encuesta Nacional de Condicionesde Vida: Guatemala, 35.5% of the San Marcos(departmental) population was indigenous,similar to the national figure of 38.4%, but SanMarcos had considerably higher levels of ex-treme poverty at 21.1% compared with 15.2%nationally.12 As shown in later tables, theproportion of indigenous population in bothmunicipalities was considerably higher thanfor the whole of the San Marcos Department,and almost 100% in Comitancillo. There are2 main seasons: the wet season occurring frommid-May until October, and the dry season,from October to May.

Sampling Methods and Survey

We sampled homes with children youngerthan 5 years from the 2 municipalities to allowcomparison of care-seeking behavior and as-sociated factors in communities known to differin cultural, language, and other respects. In late2007, we conducted a rapid census-type ap-praisal of 9503 homes, 6958 in Comitancilloand 2545 in San Lorenzo, excluding the maintowns, to identify households with young chil-dren (< 5 years) and expectant mothers, fromwhich families would be selected for the sur-vey. For Comitancillo, which covered a largegeographical area, we used stratified randomsampling to select homes that were represen-tative of one of the potential geographicalbarriers to health care access (distance fromthe health center), as follows. We listed

communities (aldeas) by time on foot to thehealth center as estimated by the local healthservices, stratifying in 30-minute groups (range30 minutes to > 4 hours), and labelled “large”or “small” according to whether the number ofhouseholds was (1) at or above or (2) below themedian for that stratum. We then calculateda target number of households from eachstratum, proportional to the percentage of allhomes in the study area provided by thatstratum, and randomly sampled aldeas fromthe “high” and “low” groups within stratumuntil the target was reached (or exceeded),resulting in a total of 1462 homes. We in-cluded all 472 homes in San Lorenzo eligible atthe time of the rapid appraisal, making a totalfor the study of 1934.

We used the survey to identify recent casesof community-acquired pneumonia and diar-rhea and what care, if any, was sought andfactors that influenced this. We carried out2 rounds of structured interviews with mothers(or main carers) approximately 7 monthsapart collecting information by maternal orcaregiver report on illness in the previous 14days affecting the youngest child in the family.We conducted 2 sets of interviews to meetthe sample size requirements—a logistic com-promise because, to have sufficient householdsin a single interview, it would have meantcarrying out the survey over a much widerarea. This would have been very resource-intensive (time, vehicle usage, and costs) anddifficult especially in the wet season when roadsare often difficult or impossible to pass. Weconducted the 2 surveys fromOctober 2008 toMay 2009, and June to December 2009, withinformed consent obtained from all partici-pants before the first interview. Interviews werecarried out by local bilingual fieldworkers usingeither Spanish orMam (the local Mayan language)according to interviewee preference. We con-ducted verbal autopsies on a sample of 30 deaths,which, in addition to obtaining the cause, wasdone to provide the basis for in-depth qualitativeinterviews on care sought and received, andwhich will be reported separately.

We conducted extensive developmentand pilot work including independent back-translation for all data collection instruments.A critical component was a 14-day calendar,which we used to record the illness and allassociated care seeking and treatment, in the

order in which this occurred, thus allowing“pathways” through multiple informal and for-mal care providers to be identified. Althoughbased on earlier use of such calendars,13 wedeveloped the instrument used in the currentstudy specifically for this purpose, and testedit over a period of 8 weeks to allow the fieldteam to become familiar with its use throughclose supervision and feedback by researchstaff. We carried out some validation of thismethodology through comparison with assess-ments made by nurse auxiliaries of a represen-tative sample of pneumonia and diarrheacases. The nurse auxiliary visits were carriedout on the same day as the survey to (1)ensure appropriate advice and help, and (2)provide independent validation of field workerassessment. The nurse auxiliary repeated thestandard questions, and carried out an exami-nation of clinical signs.

Illness and Care-Seeking Definitions

On the basis of responses during interview,we classified cases of “severe pneumonia” and“severe diarrhea” according to the reportedpresence of key symptoms and signs used forthe World Health Organization (WHO) defini-tion of community-acquired pneumonia anddiarrhea.14,15 The primary outcome for thisstudy was, among children with severe pneu-monia (requiring presence of lower chest wallindrawing or general danger signs) or severediarrhea (requiring presence of sunken eyes orgeneral danger signs) or both, care sought fromformal health services. This outcome included(1) care sought at any time during the illnessand (2) care sought within 2 days of onset. Thislatter definition served as a measure of promptcare seeking.

We investigated a range of characteristics inrelation to care seeking, including child, motherand household factors. For the child, these wereseason of illness, age, sex, and ethnicity. Fieldstaff measured height and weight at clinicsessions organized for the study, and usedstunting (height > 2 SDs below median of WHOChild Growth Standards) and underweight(weight > 2 SDs below norm) in analysis.16 Forthe mother, these were number of children inthe family, experience of previous child death,literacy, educational level, perception of illnessseverity, knowledge of Community EmergencyPlan (CEP),17 recognition of WHO danger


648 | Research and Practice | Peer Reviewed | Bruce et al. American Journal of Public Health | April 2014, Vol 104, No. 4

signs for acute lower respiratory infectionsand diarrhea, and belief in mal de ojo (“evileye”) as a cause of illness. For the household,these were municipality, distance from maintown, altitude, main language spoken, maleemployment status, crowding, access to owntransport, access to phone, asset index score(ownership of radio, television, or refrigerator,each scoring 1, and added together givinga range of 0---3), and someone available to lookafter household in emergency.

The CEP was originally developed by the USAgency for International Development, ad-ministered by the Guatemalan MSPAS, andtargeted at families in more remote areas.17 Itprovides picture-based guidance in seekingprompt, appropriate care for childhood andadult illness. Four of the WHO danger signswere common to severe pneumonia and severediarrhea (general danger signs): the child “be-ing unable to suckle or drink,” “vomitingeverything,” “having convulsions,” or “beingunconscious or lethargic.”14 One additionalsign of severe pneumonia was “lower chestwall indrawing,” and for severe diarrhea, addi-tional signs were “blood in stools” and “sunkeneyes.” We assessed knowledge of the plan atinterview by asking the parents if they werefamiliar with it, while showing them a copy. Thus,this did not test knowledge of everything coveredby the CEP, but this is in part covered by thequestions on knowledge of the WHO danger ;signs.

Statistical Analysis

We used unconditional logistic regressionto explore independent relationships betweenchild, mother, and household characteristicswith care-seeking outcomes, with 4 separatemodels covering any formal care seeking andcare seeking within 2 days, for the 2 healthoutcomes. We set an entry criterion of P < .2in univariable analysis for inclusion in multi-variable regression.

We used a multilevel (random intercepts)framework employing the GLLAMM proce-dure to adjust for children represented morethan once in the analysis (i.e., a case in bothsurvey rounds), and which provides robuststandard errors. We analyzed data with SPSSfor Windows version 18.0 (SPSS Inc, Chi-cago, IL) and Stata version 10 (StataCorp LP,College Station, TX). All P values are 2-sided.

RESULTS

We conducted a total of 3151 interviews,1605 for survey 1 (83% response rate) and1546 (96.3% re-interviewed) for survey 2.For survey 1, 403 (25.1%) resided in SanLorenzo and 1202 (74.9%) in Comitancillo.The majority of children were from theindigenous Mam linguistic group (93.2%),were stunted (60.8%), and were aged be-tween 1 and 5 years (74.7%; Table A,available as a supplement to the onlineversion of this article at http://www.ajph.org). We identified significant differencesbetween the 2 municipalities: children fromComitancillo were more likely to be female,of indigenous ethnicity, stunted, and under-weight, and were less likely to have had solidfood introduced by 6 months (P < .05).

The majority of mothers were aged 25 yearsor older (68%), were literate (65.5%), hadsome formal education (71.7%), and did notreport previous death of a child (91.9%). Morethan 40% had 3 or more children in additionto the index child. Mothers in Comitancillowere generally older, had larger families, andwere more likely to be illiterate, to bewithout formal education, and to have expe-rienced a previous death of a child (P < .05).

The majority of households were locatedmore than 5 kilometers from the main town(57.5%), included family members who spokeSpanish (60.8%), and had the male head of thefamily working as a laborer (someone paid on adaily rate for working on another’s land, in aworkshop, etc.; 58.2%). More than half used a 3-stone open fire for cooking (55%) with only 6%having access to their own car and owninga refrigerator. Households in Comitancillo weresignificantly more likely to be more than 5kilometers from the main town, to speak Mam inthe household, to have a male head of thehousehold working as a laborer, to be over-crowded, to have only an open fire for cooking,and to have no ownership of a car, phone,radio, TV, or refrigerator (P < .05).

Although reported knowledge of the CEPmay not be wholly reliable as a measure ofactual familiarity with details of the plan andreadiness to act on the advice, it does providesome indication of this. Knowledge of theCEP was significantly lower in Comitancillo,

among indigenous households, in thosespeaking Mam, for mothers who were illiter-ate and less educated, and among farminghouseholds (Table 1). Knowledge was alsolower among those with no phone, livingfarther from the main town, and where therehad been a previous child death. Mothersreporting that there was no one else to lookafter the family in an emergency were morelikely to know the CEP. In multivariableanalysis, significant associations remained fora number of these variables, but not formunicipality and language spoken at home(Table 1). Perhaps surprisingly, previousdeath of a child and having someone to lookafter the family in an emergency were asso-ciated with a lower likelihood of knowing theCEP.

We found somewhat weaker associationsbetween knowing 1 or more WHO dangersigns for pneumonia and diarrhea and munic-ipality, ethnicity, and having someone to lookafter the family in an emergency (pneumoniaonly; Table 2). In multivariable analysis, onlyasset index remained significantly (P= .03)associated with knowledge of danger signs fordiarrhea, albeit negatively.

Based on responses to the 3151 interviewsrelating to recent (previous 14 days) healthof children, the number (prevalence) of cases ofsevere pneumonia and severe diarrhea were364 (11.6%) and 481 (15.3%), respectively.There were 185 cases of severe pneumonia inround 1 and 179 in round 2, with 31 havingan episode in both surveys. For severe diar-rhea, there were 232 cases in round 1 and 249in round 2, with 59 having an episode in bothsurveys. In the nurse auxiliary validation study,which analyzed 272 cases of possible commu-nity-acquired pneumonia according to mater-nal report that were also examined by thenurse auxiliary, a total of 147 (54%) wereconfirmed by nurse auxiliary assessment(j= 0.49). For the 472 survey-defined cases ofdiarrhea, 396 (83.9%) were confirmed bynurse auxiliary (j= 0.74). Analysis offactors associated with care seeking amongnurse auxiliary ascertained cases generallyconfirmed results from the main survey.

First Source of Care Sought

Among the 364 severe pneumonia cases,around 5% of families sought no care, from



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either formal or informal health care pro-viders (Table 3). For a little more than 20%,the first point of contact for advice was one ofthe formal health care providers, but informal

agencies were more frequently the first con-tact point (local store, 24.7%; relative, 18.4%;pharmacy, 16.5%). In San Lorenzo, 39%of mothers with a child with severe pneumonia

went to a health center or health post firstcompared to only 14.1% in Comitancillo(P < .001), although the local store wascommonly approached first in both

TABLE 1—Associations Between Socioeconomic Factors and Knowledge of the Community Emergency Plan: San Marcos, Guatemala,

2008–2009

Characteristic No. of Mothers Knowing CEP (%) OR (95% CI) P AOR (95% CI) P

Municipality

Comitancillo 664 (55.2) 1.00 (Ref) 1.00 (Ref)

San Lorenzo 282 (70.1) 1.90 (1.50, 2.43) <.001 1.39 (0.98, 1.97) .07

Ethnicity

Ladino 83 (76.9) 1.00 (Ref) 1.00 (Ref)

Indigenous 862 (57.8) 0.43 (0.27, 0.67) <.001 0.78 (0.50, 1.33) .36

Language at home

Mam only (Ref) 681 (55.5) 1.00 (Ref) 1.00 (Ref)

Spanish 176 (72.1) 2.07 (1.53, 2.80) <.001 1.26 (0.98, 1.64) .07

Mother literate

Yes 665 (63.4) 1.00 (Ref) 1.00 (Ref)

No 176 (50.5) 0.80 (0.73, 0.87) <.001 0.83 (0.48, 1.49) .57

Mother’s education

None 228 (50.2) 1.00 (Ref) 1.00 (Ref)

Elementary 537 (62.6) 1.66 (1.32, 2.09) <.001 1.28 (0.70, 2.34) .43

> elementary 181 (62.0) 1.62 (1.19, 2.18) .002 1.33 (0.82, 2.17) .25

Previous death of child

No 889 (60.3) 1.00 (Ref) 1.00 (Ref)

Yes 57 (43.8) 0.51 (0.36, 0.74) <.001 0.57 (0.38, 0.86) .007

Possess phone

Yes 735 (61.1) 1.00 (Ref) 1.00 (Ref)

No 211 (52.6) 0.71 (0.56, 0.88) .003 0.84 (0.64, 1.10) .2

Overcrowding

No 499 (60.7) 1.00 (Ref) 1.00 (Ref)

Yes 447 (57.2) 0.86 (0.71, 1.03) .15 1.02 (0.81, 1.30) .81

Someone to look after family in emergency

No 258 (64.5) 1.00 (Ref) 1.00 (Ref)

Yes 688 (57.1) 0.88 (0.81, 0.97) .01 0.63 (0.48, 0.82) .001

Employment status of head of household

Farmer (Ref) 102 (48.6) 1.00 (Ref) 1.00 (Ref)

Laborer 554 (60.5) 1.62 (1.20, 2.19) .002 2.13 (1.50, 3.02) .001

Self-employed 77 (59.7) 1.57 (1.01, 2.44) .04 1.30 (0.79, 2.14) .3

Other 192 (60.4) 1.61 (1.14, 2.29) .008 1.67 (1.11, 2.52) .01

Access to transport

None 685 (58.7) 1.00 (Ref)

Bike or motorcycle 193 (58.5) 0.99 (0.77, 1.27) .95

Car or pickup truck 68 (63.6) 1.22 (0.81, 1.85) .33

Asset indexa

Score 0–1 539 (55.6) 1.00 (Ref) 1.00 (Ref)

Score 2–3 407 (64.1) 1.42 (1.15, 1.75) .001 1.39 (1.08, 1.79) .01

Distance from town: 1 km closer 1.06 (1.03, 1.08) <.001 01.02 (0.99, 1.06) .16

Note. AOR = adjusted odds ratio; CEP = Community Emergency Plan; CI = confidence interval; OR = odds ratio. Mam is the local Mayan language.aBased on radio, TV, or refrigerator ownership.



municipalities (25.5% and 22.9%, respec-tively; P = .61).

For the 481 severe diarrhea cases, 7% ofmothers sought no care at all. The local storewas used more frequently than for severe pneu-monia (36% compared with 25% for severepneumonia). A higher proportion of severediarrhea cases in San Lorenzo were initiallytaken to a health center or post than in Com-itancillo (21% vs 6.5%, respectively; P < .001).

Formal Care for Severe Pneumonia

Of the 364 cases of severe pneumonia,formal care was sought for 181 (49.7%). Fora quarter (n = 98) of cases, formal care wassought within 2 days of onset. Table 4 showsassociations between child, mother, andhousehold characteristics and care-seekingoutcomes for which the entry criterion ofP < .2 in univariable analysis was met. Factorssignificantly associated in univariable analysiswith formal care seeking at any time in theepisode (P < .05) included a higher level ofmaternal education, perception of a greaterillness severity, knowledge of the CEP,San Lorenzo residence, and recognitionof WHO danger signs. Multivariableanalysis identified 2 independent factorsfor formal care seeking: mother’s per-ception of severity (adjusted odds ratio[OR] = 2.05; 95% confidence interval [CI] =1.05, 4.03) and maternal recognition ofWHO danger signs (adjusted OR = 2.14;95% CI = 1.32, 3.47).

In relation to prompt (within 2 days) formalcare seeking, 2 factors were significantly(P < .05) associated in univariable analysis:maternal literacy and higher level of maternaleducation. None of the household, child, andmother characteristics were significantly asso-ciated with prompt care seeking in multivari-able analysis, although distance to town wasof borderline significance (1 km closer OR =1.08; 95% CI = 0.99, 1.16). Analysis of factorsindependently associated with formal careseeking for severe pneumonia within 2 daysamong the subset of 181 cases seeking formalcare at any time did not identify any significantfindings.

Formal Care for Severe Diarrhea

Of the 480 cases of severe diarrhea, formalhelp was sought for 147 (30.6%). For almost

TABLE 2—Associations Between Socioeconomic Factors and Knowledge of the World Health

Organization Danger Signs for Severe Pneumonia and Severe Diarrhea: San Marcos,

Guatemala, 2008–2009

Characteristic

No. of Mothers Knowing

WHO Danger Signsa (%) OR (95% CI) P AOR (95% CI) P

Severe pneumonia

Municipality


San Lorenzo 150 (37.2) 1.42 (1.13, 1.81) .003 1.32 (0.95, 1.86) .1

Ethnicity

Ladino 44 (40.4) 1.00 (Ref) 1.00 (Ref)

Indigenous 458 (30.7) 0.66 (0.44, 0.98) .04 0.94 (0.58, 1.52) .81

Language at home

Mam only 367 (29.9) 1.00 (Ref) 1.0

Spanish 87 (35.7) 1.29 (0.97, 1.73) .08 0.93 (0.72, 1.21) .6

Mother literate

Yes 332 (31.6) 1.00 (Ref)

No 171 (30.9) 0.98 (0.84, 1.14) .76


None 134 (29.5) 1.00 (Ref)

Elementary 266 (31.0) 1.07 (0.84, 1.38) .58

> elementary 103 (35.2) 1.30 (0.95, 1.77) .11


No 466 (31.6) 1.00 (Ref)

Yes 37 (28.5) 0.86 (0.58, 1.28) .46

Possess phone

Yes 392 (32.6) 1.00 (Ref) 1.00 (Ref)

No 111 (27.7) 0.79 (0.62, 1.02) .07 0.83 (0.63, 1.10) .2

Overcrowding

No 265 (32.2) 1.00 (Ref)

Yes 238 (30.4) 0.92 (0.75, 1.14) .45

Someone to look after family

in emergency

No 108 (27.0) 1.00 (Ref) 1.00 (Ref)

Yes 395 (32.8) 1.21 (1.01, 1.45) .03 0.79 (0.58, 1.03) .09

Employment status of head

of household

Farmer 73 (34.8) 1.00 (Ref)

Laborer 276 (30.1) 0.81 (0.59, 1.11) .19

Self-employed 41 (31.8) 0.87 (0.55, 1.40) .57

Other 106 (33.9) 0.94 (0.64, 1.36) .73

Access to transport

None 366 (31.4) 1.00 (Ref)

Bike or mortorcycle 100 (30.3) 0.95 (0.73, 1.24) .71


Asset indexb

Score 0–1 300 (31.0) 1.00 (Ref)

Score 2–3 203 (31.9) 1.04 (0.84, 1.30) .69

Distance from town: 1 km closer 1.02 (0.99, 1.05) .07 1.02 (0.98, 1.05) .32

Continued



a fifth (n = 86), formal help was sought within 2days. For formal care seeking at any timeduring the episode (Table 4), we observeda significant association in univariable analysis(P < .05) for a higher level of maternal educa-tion, greater perceived severity of illness,knowledge of CEP, child’s ethnic group beingLadino, and a closer proximity to the maintown. Three factors were independently asso-ciated with formal care seeking in the multi-variable model: mother’s perception of severity(adjusted OR = 2.22; 95% CI = 1.14, 4.35),knowledge of the CEP (adjusted OR = 1.73;95% CI = 1.09, 2.76), and distance from themain town (1 km closer, adjusted OR = 1.11;95% CI = 1.04, 1.18). Three factors weresignificantly (P < .05) associated in univariableanalysis with prompt formal care seeking(Table 4): Ladino ethnicity, San Lorenzo resi-dence, and proximity to the main town.

We found 2 factors to be independentlyassociated with prompt care seeking in themultivariable model: proximity to the maintown (1 km closer, adjusted OR = 1.12; 95%CI = 1.03, 1.22) and availability of someone tolook after the household in an emergency(adjusted OR = 2.01; 95% CI = 1.10, 3.68).Analysis of factors independently associatedwith formal care seeking for severe diarrheawithin 2 days among the subset of 147 casesseeking formal care at any time identifiedsomeone to look after the children in anemergency (OR = 2.98; 95% CI = 1.48, 6.62)as the only significant finding.

DISCUSSION

In this study, recent and current episodes ofpneumonia and diarrhea were identified byparental interview using recall of establishedcriteria for community cases. The reportedprevalence rates for severe pneumonia(11.6%) and severe diarrhea (15.3%) are high,but consistent with estimates derived fromsimilar questions used, for example, in Demo-graphic and Health Surveys,18 and reflect thesensitive but nonspecific characteristics ofthis method.19 The nurse auxiliary validationstudy showed reasonable agreement withfieldworker interviews, allowing for theexpected lower specificity of the latter. Fur-thermore, it is important that care is sought forsick children who—on the basis of symptoms or

TABLE 2—Continued

Severe diarrhea

Municipality


San Lorenzo 144 (35.7) 1.27 (0.99, 1.61) .05 1.09 (0.80, 1.48) .58

Ethnicity

Ladino 45 (40.9) 1.00 (Ref) 1.00 (Ref)

Indigenous 465 (31.2) 0.65 (0.44, 0.97) .04 0.74 (0.47, 1.16) .19

Language at home

Mam only 385 (31.4) 1.00 (Ref)

Spanish 80 (32.8) 1.07 (0.79, 1.43) .67

Mother literate

Yes 341 (32.5) 1.00 (Ref)

No 169 (30.5) 1.10 (0.88, 1.37) .42


None 137 (30.2) 1.00 (Ref)

Elementary 274 (31.9) 1.09 (0.85, 1.39) .51

> elementary 100 (34.1) 1.20 (0.88, 1.64) .26


No 465 (31.5) 1.00 (Ref)

Yes 46 (35.4) 1.18 (0.82, 1.73) .37

Possess phone

Yes 394 (32.7) 1.00 (Ref) 1.00 (Ref)

No 117 (29.2) 0.85 (0.66, 1.08) .19 0.81 (0.62, 1.06) .12

Overcrowding

No 268 (32.6) 1.00 (Ref)

Yes 243 (31.1) 0.93 (0.76, 1.15) .52

Someone to look after family

in emergency

No 120 (30.0) 1.00 (Ref)

Yes 391 (32.4) 1.08 (0.91, 1.28) .36

Employment status of head

of household

Farmer 69 (32.9) 1.00 (Ref)

Laborer 284 (31.0) 0.92 (0.67, 1.27) .6

Self-employed 41 (31.8) 0.95(0.16, 1.52) .84

Other 111 (34.9) 1.10 (0.76, 1.59) .63

Access to transport

None 380 (32.6) 1.00 (Ref)

Bike or motorcycle 96 (29.1) 0.85 (0.65, 1.11) .23


Asset indexb

Score 0–1 323 (33.3) 1.00 (Ref) 1.00 (Ref)

Score 2–3 188 (29.6) 0.84 (0.67, 1.04) .11 0.70 (0.50, 0.96) .03

Distance from town: 1 km closer 1.03 (0.99, 1.06) .06 1.02 (0.99, 1.06) .17

Note. AOR = adjusted odds ratio; CI = confidence interval; OR = odds ratio; WHO = World Health Organization. Mam is thelocal Mayan language.aIncludes the WHO general danger signs and those specific to the disease.bBased on radio, TV, or refrigerator ownership.



signs apparent to parents—may have severepneumonia or diarrhea (and not just clinicallyconfirmed cases). Therefore, despite the sen-sitive but nonspecific case ascertainment, thefindings are relevant to the primary goal ofthis work—to inform interventions forimproving more complete and rapid careseeking.

Formal and Informal Sources of Care

Sick children may deteriorate rapidly, sotime taken to obtain trained medical attentionis very important, whatever the initial sourceof advice. In our study, the most commonsource of initial help was informal, with chil-dren from Comitancillo being less likely to firstattend a health center or health post. Thelocal store and pharmacy were popular assources of initial advice, regardless of munici-pality or the specific child’s illness.

Pharmacies may provide some degree offormal care, either in assessment of a sick child,or in the direct or indirect (following medical

assessment) prescription of appropriate treat-ment. We found that 63 and 70 cases of severepneumonia and severe diarrhea, respectively,involved a pharmacy visit (either initial orsubsequent), but in only 2 and 1 of these,respectively, was this subsequent to a formal(MSPAS or EdC) visit. The pharmacy was thesource of antibiotics in 22% (n = 18) of severepneumonia cases that received these, and oforal rehydration solutions in 12% (n = 9) of thesevere diarrhea cases that received these, somost of these must have been direct over-the-counter dispensing. Thus, a minority of phar-macy visits may have provided something akinto formal care, but full assessment of theappropriateness of this would require furtherinvestigation. Among the more importantfindings from the qualitative component of thestudy were that mothers placed much faith inherbal remedies, treatments known to be un-available and disapproved of in the MSPASfacilities, but easily available in the local storeor pharmacy.

Factors Associated With Formal Care

Seeking

Previous research from Africa, South Asia,and Latin America of factors associated withdecreased likelihood to seek formal care forsick children has identified lower educationallevel,20,21 younger maternal age,22 indigenousethnicity,23,24 lower occupational status,7

lack of perceived illness severity,8,25 and deathof a previous child.26 In addition, child’s age,27

nutritional status,28 and socioeconomic fac-tors20,29---34 have been reported as being asso-ciated with care-seeking behavior. Althoughindigenous ethnicity might be thought to bea useful indicator and basis for analysis, ourunderstanding (from observation and localpartners) is that those describing themselves asindigenous in the more Ladino, acculturatedSan Lorenzo differ from those in Comitancillo.This is borne out by the finding that 95.9%of indigenous families in San Lorenzo speakSpanish at home compared with only 48.7%in Comitancillo.

In our survey, many of these factors (orclosely associated variables) were associatedwith formal care seeking in univariable analy-sis, but were not independent predictors inmultivariable analysis. The factors that stoodout as independent predictors were themother’s perception of the child’s illness se-verity, knowledge of the emergency plan, andthe ability to identify WHO signs of severeillness. Distance from the main town was alsosignificant for diarrhea (P= .002; formal careat any time), but not for formal care forpneumonia sought within 2 days (P= .06).These findings lend support to the potentialeffectiveness of comprehensive educational in-terventions, focusing on prompt recognition ofwarning signs and preparing for an emergency,especially for severe illness. However, there isstrong evidence from our study (Table 1) thatknowledge of the CEP, and to some extent therecognition of danger signs (Table 2), vary sub-stantially according to a number of importantsocial, geographic, and asset-related characteris-tics, although these are weaker in adjustedanalysis because of the strong interrelationships.The fact that municipality, maternal literacy, andeducational level lose significance in the multi-variable analysis of factors associated with careseeking should not be interpreted as meaningthat these are unimportant for policy.

TABLE 3—First Agency Contacted for Health Care and Advice Relating to the Sick Child

Younger Than 5 Years: San Marcos, Guatemala, 2008–2009

Severe Pneumonia Episodes, % Severe Diarrhea Episodes, %

Agency First

Sought for Help All (n = 364)

Comitancillo

(n = 255)

San Lorenzo

(n = 109) All (n = 481)

Comitancillo

(n = 371)

San Lorenzo

(n = 110)

No help sought 4.7 5.9 1.8 6.7 5.5 10.9

Community providers 65.2 68.7 57.7 77.6 81.1 65.6

Relative 18.4 20.8 12.8 21.0 21.3 20.2

Neighbors 3.8 3.9 3.7 6.9 7.8 3.6

Healer 0.8 0.8 0.9 1.5 1.6 0.9

Midwife 0.5 0.8 0 0.6 0.8 0

Medicine seller 0.5 0.4 0.9 1.2 1.3 0.9

Local store 24.7 25.5 22.9 35.8 37.5 30.0

Pharmacy 16.5 16.5 16.5 10.6 10.8 10.0

MSPAS and EdC 26.1 20.4 36.7 13.1 10.8 20.9

EdC facilitator 5.2 5.5 0 3.3 4.3 0

Health post 6.0 4.3 10.1 2.1 0.8 6.4

Health center 14.1 9.8 25.7 7.7 5.7 14.5

National hospital 0.8 0.8 0.9 0 0 0

Private 3.3 3.4 3.7 2.5 2.4 2.7

Private doctor 1.9 1.6 2.8 1.0 0.8 1.8

Private hospital 1.4 1.6 0.9 1.5 1.6 0.9

Note. EdC = Programme to Extend Coverage of Basic Health Services (Extension de Cobertura); MSPAS = Ministry of PublicHealth and Social Assistance. Chi-squared test for comparison between municipalities at level of headings (no help sought,community providers, MSPAS and EdC, and private): Comitancillo severe pneumonia episodes, P = .03; all severe diarrheaepisodes, P = .009.



TABLE 4—Associations for Factors Related to Formal Care Seeking for Children Younger Than 5 Years With Severe Pneumonia

and Severe Diarrhea: San Marcos, Guatemala, 2008–2009

Variable No. of Episodes (%) Unadjusted OR (95% CI) P Adjusted ORa (95% CI) P

Severe pneumonia: formal care seeking any time during episode

Age of child

< 12 mo 66 (55.5) 1.00 (Ref) 1.00 (Ref)

1–5 y 114 (46.9) 0.71 (0.46, 1.10) .13 0.73 (0.44, 1.21) .22

Gender of child

Male 97 (55.4) 1.00 (Ref) 1.00 (Ref)

Female 83 (45.6) 0.67 (0.44, 1.02) .06 0.76 (0.48, 1.21) .25

Underweight (weight 2 SD below norm)

No 123 (53.0) 1.00 (Ref) 1.00 (Ref)

Yes 49 (44.5) 0.71 (0.45, 1.12) .14 0.83 (0.50, 1.38) .47

Mother’s education level

None 43 (44.8) 1.00 (Ref) 1.00 (Ref)

Elementary 98 (48.5) 1.16 (0.71, 1.89) .55 0.97 (0.56, 1.68) .91

> elementary 40 (60.6) 1.90 (1.01, 3.59) .04 1.53 (0.74, 3.17) .25

Mother’s perceived severity of illness episode

Not serious 24 (42.1) 1.00 (Ref) 1.00 (Ref)

Serious 77 (45.6) 1.15 (0.63, 2.11) .65 1.11 (0.58, 2.14) .75

Very serious 80 (58.4) 1.93 (1.03, 3.61) .04 2.05 (1.05, 4.03) .04

Mother knows emergency plan

No 40 (39.2) 1.00 (Ref) 1.00 (Ref)

Yes 141 (53.8) 1.81 (1.13, 2.88) .01 1.59 (0.97, 2.62) .07

Municipality


San Lorenzo 64 (58.7) 1.67 (1.06, 2.64) .03 1.65 (0.96, 2.84) .07

Asset index scoreb

0–1 105 (46.9) 1.00 (Ref) 1.00 (Ref)

2–3 76 (54.3) 1.35 (0.88, 2.06) .17 1.29 (0.79, 2.09) .31

Mother recognized WHO sign

No 52 (37.7) 1.00 (Ref) 1.00 (Ref)

Yes 129 (57.1) 2.20 (1.43, 3.39) .001 2.14 (1.32, 3.47) .002

Severe pneumonia: formal care seeking within 2 days of onset

Gender of child

Male 54 (30.9) 1.00 (Ref) 1.00 (Ref)

Female 43 (23.6) 0.69 (0.43, 1.11) .13 0.83 (0.50, 1.35) .44

Mother experienced previous death of a child

No 93 (28.1) 1.00 (Ref) 1.00 (Ref)

Yes 5 (15.2) 0.46 (0.17, 1.22) .11 0.49 (0.18, 1.34) .17

Mother’s literacy

Illiterate 21 (18.9) 1.00 (Ref) 1.00 (Ref)

Literate 77 (30.4) 1.88 (1.09, 3.24) .02 2.13 (0.60, 7.58) .24


None 18 (18.8) 1.00 (Ref) 1.00 (Ref)

Elementary 58 (28.7) 1.75 (0.98, 3.17) .07 0.73 (0.18, 2.94) .66

> elementary 22 (33.3) 2.17 (1.05, 4.47) .04 0.97 (0.27, 3.51) .96

Continued



TABLE 4—Continued


No 21 (20.6) 1.00 (Ref) 1.00 (Ref)

Yes 77 (29.4) 1.61 (0.93, 2.78) .09 1.46 (0.83, 2.56) .19

Municipality


San Lorenzo 36 (33.0) 1.53 (0.94, 2.51) .09 1.11 (0.65, 1.89) .70

Someone to look after household in emergency

No 24 (21.2) 1.00 (Ref) 1.00 (Ref)

Yes 74 (29.5) 1.55 (0.92, 2.62) .10 1.43 (0.83, 2.49) .20

Location of household: 1 km closer to town 1.06 (0.99, 1.15) .05 1.08 (0.99, 1.16) .06

Severe diarrhea: formal care seeking any time during episode

Age of child

< 12 mo 47 (36.7) 1.00 (Ref) 1.00 (Ref)

1–5 y 100 (28.6) 0.69 (0.45, 1.06) .09 0.79 (0.49, 1.26) .32

Ethnic group of child

Non-Indigenous 12 (52.2) 1.00 (Ref) 1.00 (Ref)

Indigenous 135 (29.7) 0.39 (0.17, 0.90) .02 0.55 (0.20, 1.49) .24

Mother’s literacy


Literate 102 (33.1) 1.39 (0.92, 2.12) .11 1.23 (0.48, 3.19) .67


None 36 (24.8) 1.00 (Ref) 1.00 (Ref)

Elementary 76 (31.3) 1.38 (0.87, 2.19) .18 0.97 (0.33, 2.81) .95

> elementary 35 (38.0) 1.86 (1.06, 3.27) .03 1.31 (0.52, 3.34) .57



Serious 69 (27.5) 1.37 (0.74, 2.55) .31 1.23 (0.66, 2.40) .53

Very serious 62 (40.0) 2.42 (1.27, 4.58) .007 2.22 (1.14, 4.35) .02


No 38 (24.1) 1.00 (Ref) 1.00 (Ref)

Yes 109 (33.9) 1.62 (1.05, 2.49) .03 1.73 (1.09, 2.76) .02

Municipality


San Lorenzo 42 (38.2) 1.56 (0.99, 2.44) .052 1.21 (0.66, 2.22) .55

Mother believed in mal de ojo

No 138 (31.9) 1.00 (Ref) 1.00 (Ref)

Yes 9 (19.1) 0.51 (0.24, 1.08) .07 0.58 (0.27, 1.27) .18


Severe diarrhea: formal care seeking within 2 days of onset

Ethnic group of child

Non-Indigenous 8 (34.8) 1.00 (Ref) 1.00 (Ref)

Indigenous 78 (17.1) 0.39 (0.16, 0.95) .03 0.63 (0.22, 1.81) .39

Mother experienced previous death of a child

No 81 (18.7) 1.00 (Ref) 1.00 (Ref)

Yes 5 (10.6) 0.52 (0.20, 1.35) .17 0.69 (0.25, 1.88) .47

Mother’s literacy


Literate 62 (20.1) 1.55 (0.93, 2.60) .09 1.31 (0.74, 2.34) .36

Continued



Integrated Management

Awareness-raising interventions are consis-tent with the Integrated Management ofChildhood Illness guidelines,35 which recom-mend a 3-pronged approach. The componentof "improving family and community practicesthrough education of mothers, fathers, otherchild caretakers, and members of the commu-nity, with a focus on health seeking behaviour,compliance, care at home and on overallhealth promotion"36 relates closely to thesurvey findings reported in this article. Supply-side results relating to the other 2 components,improving case management skills of healthcare staff and improving overall health systems,will be reported separately.

An expanded role for community healthworkers offers one means of raising awareness,especially in more remote social and geo-graphical groups. In the poorer municipalitiesof Guatemala, working alongside contractednongovernmental organizations, the commu-nity health worker (promotor de salud) has beena key component in the EdC. This servicehas historically focused mainly on prevention,

but was also intended to contribute to caserecognition and treatment. In this study,whether or not they were aware of this com-ponent of the role of EdC, parents soughtadvice and treatment from this source in veryfew cases. Furthermore, the few consultationsresulted in almost no referrals to the healthcenters. This indicates that, in practice, EdCis not providing an effective or trusted com-munity health worker---based service. This com-ponent of the Guatemalan health service iscurrently being reassessed. In doing so, it will beimportant to determine what arrangements canbest fulfil the community health worker role.

Conclusions

The factors most strongly associated with careseeking were knowledge of CEP, and recogni-tion of severity of the illness, whether this wasthe mother’s own perceptions, or knowledge oftheWHO danger signs. Having someone to lookafter the family in an emergency was alsoimportant, and is a topic covered by the CEP.Greater distance (assessed by time on foot)from the health centers, which are located in

the main town in each municipality, was a bar-rier. These results suggest that the CEP maywell be effective, although the current studydesign does not allow a firm cause-and-effectassociation to be assumed. Awareness of theCEP, assessed by a simple question on recog-nition (and showing the plan), was reportedby 70.1% in San Lorenzo, but reported bya little more than half (55.2%) of homes inComitancillo, so it needs to be extended. Re-sponsibility for promoting the CEP and in-creasing awareness of the need to seek earlymedical advice lies primarily with MSPAS, butcould be enhanced by working with communityleaders, and involving pharmacies and schools.Bilingual (Mam, Spanish) community healthworkers have a key role, not only in awarenessraising, but also in being easily available tomake initial assessments of sick children andsupporting families to overcome barriers toearly facility-based care seeking.

Underlying the importance of the CEPand knowledge of danger signs is the fact thatthese remain strongly associated with poorersocioeconomic conditions, and more remote

TABLE 4—Continued



Serious 43 (17.1) 1.49 (0.69, 3.23) .31 1.32 (0.59, 2.95) .51

Very serious 34 (21.9) 2.03 (0.92, 4.49) .08 1.66 (0.72, 3.87) .24


No 23 (14.6) 1.00 (Ref) 1.00 (Ref)

Yes 63 (19.6) 1.43 (0.85, 2.40) .18 1.58 (0.88, 2.80) .12

Municipality


San Lorenzo 29 (26.4) 1.97 (1.18, 3.27) .009 1.32 (0.62, 2.81) .47

Main language spoken in household

Mam only 28 (15.6) 1.00 (Ref) 1.00 (Ref)

Spanish first or second language 54 (20.5) 1.40 (0.85, 2.32) .19 0.85 (0.46, 1.56) .59

Someone to look after household in emergency

No 22 (14.4) 1.00 (Ref) 1.00 (Ref)

Yes 64 (19.6) 1.45 (0.86, 2.46) .17 2.01 (1.10, 3.68) .02

Mother believed in mal de ojo

No 82 (18.9) 1.00 (Ref) 1.00 (Ref)

Yes 4 (8.5) 0.40 (0.14, 1.14) .08 0.44 (0.15, 1.32) .14


Note. CI = confidence interval; mal de ojo = "evil eye"; OR = odds ratio; WHO = World Health Organization. Formal care includes all government and private medical services including extension ofcover (Programme to Extend Coverage of Basic Health Services [Extension de Cobertura]). Mam is the local Mayan language.aAdjusted for all variables listed in unadjusted column (P < .02 in univariable analysis).bBased on radio, TV, or refrigerator ownership.



geographical location. As a consequence, actionstaken by MSPAS should be designed to respondto where need is greatest, but also be comple-mented by efforts to improve these underlyingconditions, including women’s education andlanguage skills, transport and road infrastructure,and financial constraints. A systems approach ishelpful,37 as it promotes coordinated action inrespect of health services, community healthworkers, traditional providers (including phar-macies, shops, and healers), community develop-ment, education and literacy, and transport. j

About the AuthorsNigel Bruce, Daniel Pope, Christopher Shiels, and DebbiStanistreet are with the Department of Public Health andPolicy, University of Liverpool, Liverpool, UK. At the time ofthe study, Byron Arana, Carolina Romero, and RobertKlein were with the Center for Health Studies, University delValle, Guatemala City, Guatemala.Correspondence should be sent to Professor Nigel Bruce,

Department of Public Health and Policy, University ofLiverpool, Whelan Building, L693GB United Kingdom(e-mail: [email protected]). Reprints can be ordered athttp://www.ajph.org by clicking the “Reprints” link.This article was accepted on August 30, 2013.

ContributorsN. Bruce, D. Pope, B. Arana, C. Romero, R. Klein, andD. Stanistreet were involved in all stages of the project,from design through data collection and analysis, andarticle preparation. C. Romero was the field projectmanager based in San Lorenzo, Guatemala. C. Shielsperformed data cleaning and analysis and contributed toarticle preparation.

AcknowledgmentsFunding for the study was provided by the UBS OptimusFoundation.

We wish to acknowledge the invaluable support andadvice provided by Elisa Barrios, MD (Jefatura del Areade Salud de San Marcos, Ministerio de Salud Publica yAsistencia Social de Guatemala) and her staff at all stagesof the study, and in particular during discussions ofstudy findings with district health system personnel.We would like to thank the communities for theircooperation, Rudinio Avecido for the preparation andmanagement of databases, and all field staff and super-visors for their diligent work. Thanks also to Don deSavigny of the Swiss Tropical Institute and Martin Weberof World Health Organization for their valuable advice.

Human Participant ProtectionEthical approval was obtained from the institutionalreview board at the University del Valle, Guatemala City,Guatemala, which was also accepted by the University ofLiverpool, UK.

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