BMJ  2004;329:266 (31 July), doi:10.1136/bmj.38149.703380.47 (published 20 July 2004)

Primary care

Impact of counselling on careseeking behaviour in families with sick children: cluster randomised trial in rural India

¹ Child Health Program, Action Research and Training for Health (ARTH), 39 Fatehpura, Udaipur, India 313004, ² Department of Child and Adolescent Health and Development, World Health Organization, CH1211 Geneva, Switzerland, ³ Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London WC1E 7HT

Abstract

Objective To assess whether training doctors in counselling improves careseeking behaviour in families with sick children.

Design Pair matched, community randomised trial conducted in 12 primary health centres (six pairs). Doctors in intervention centres were trained in counselling, communication, and clinical skills, using the integrated management of childhood illness approach.

Setting Rural district in Rajasthan, India.

Participants Children aged under 5 years presenting for curative care and their mothers were recruited and visited monthly at home for six months. A total of 2460 children were recruited (1248 intervention, 1212 control).

Main outcome measures Careseeking behaviour of mothers for sick children; mothers' knowledge and perceptions of seeking care; counselling performance of doctors.

Results For episodes of illness with at least one reported danger sign, 15% of intervention group mothers and 10% of control group mothers reported having sought care from an appropriate provider promptly; this difference was not statistically significant (relative risk reduction 5%, 95% confidence interval -0.4% to 11%; P = 0.07). One month after training, intervention site doctors counselled more effectively than control group doctors, but at six months their performance had declined. A greater proportion of mothers in the intervention group than in the control group recalled having had at least one danger sign explained (45% v 8%; P = 0.02).

Conclusions Mothers' appreciation of the need to seek prompt and appropriate care for severe episodes of childhood illness increased, but their careseeking behaviour did not improve significantly.

Introduction

Delays in seeking appropriate care, and not seeking care at all, contribute to the large number of child deaths in developing countries.^1-4 The World Health Organization estimates that seeking prompt and appropriate care could reduce child deaths due to acute respiratory infections by 20%.⁵

The integrated management of childhood illnesses (IMCI) strategy, besides improving providers' skills in managing childhood illnesses, aims to improve families' careseeking behaviour. Health workers are trained to teach mothers about danger signs and counsel them on the need to seek care promptly if these signs occur.⁶

Interventions to improve careseeking have been proposed, but their impact has not been evaluated. This trial assessed whether training healthcare providers in counselling and communication improves the careseeking behaviour of families that subsequently consult them.

Subjects and methods

Study population
Udaipur, a district in Rajasthan, India, has a population of 2.6 million, 80% of which is rural. Only 44% of women are literate. The public health system comprises 92 primary health centres and 538 subcentres, with a tertiary referral hospital in Udaipur city. Curative services at primary health centres are provided primarily by doctors; auxiliary nurse midwives provide preventive services.

Sampling and randomisation
Our sampling frame comprised 29 primary health centres where a doctor lived in the village. We randomly selected six centres from this list and matched each as closely as possible with a centre with similar caseload, location, and socioeconomic status of catchment population. One centre from each pair was randomly allocated to the intervention.

Intervention
We adapted the training modules of the integrated management of childhood illness strategy, strengthening the sections on counselling and communication with other material.⁷ We used the guidelines on rapid identification of local terminology to identify local terms for illnesses and danger signs.⁸

Doctors at intervention sites underwent a five day training programme to teach mothers about signs indicating serious illness and to counsel them on the need to seek care promptly if these signs occur. A card with pictures and messages (child health card; see bmj.com) was developed to assist in counselling and copies of these cards were given to intervention site doctors to distribute to mothers. Control site doctors were trained over a period of one to three days in clinical skills alone.

Recruitment and data collection
Enrolment began on 1 January 2002. We aimed to recruit 200 mothers bringing children aged under 5 years for curative care.

About one month after enrolment a field worker made a follow up home visit to collect social, economic, and demographic information. The mother was asked to recall their interaction with the doctor during the visit when they were enrolled in the study. In addition, the mother was presented with three scenarios concerning sick children who had danger signs, and asked for her views on appropriate responses. At this visit, and at five subsequent monthly visits, we used standard questions, supplemented by open narratives, to ask mothers about episodes of illness during the previous month, the care sought, and the treatment given.

The precise objectives of the study were not disclosed to the doctors or field workers. One and six months after training, we observed each doctor in 10 consultations with children and recorded details of their counselling performance.

Sample size calculations and data analysis
We estimated that 1060 children would be needed in each group to provide 80% power at the 5% significance level. Allowing for 10% losses to follow up, we planned to recruit 1160 children in each group.

Mothers' knowledge of care seeking, recall of counselling messages, responses to hypothetical scenarios, and care seeking practices were compared between the two groups. See bmj.com for details of sample size calculation and data analysis.

Results

Of 2460 eligible children seen at primary health centres, at least one follow up home visit was completed for 2280 (93%; range 89 to 258 per centre). Follow up was similar in the intervention and control groups (1163/1248, 93%, and 1117/1212, 92%). Of children completing at least one visit, 894 (77%) in the intervention and 914 (82%) in the control group completed all six visits. The mean numbers of completed visits were 5.5 in the intervention and 5.6 in the control group.

Children in the intervention group were slightly younger than those in the control group (mean 1.26 v 1.44 years). A higher proportion of intervention children came from the scheduled caste or tribes. Mothers in the intervention group were less likely to be literate than their control counterparts, but tended to be less poor. Control children lived further away from the primary care facility at which they were enrolled but were more likely to have been born in a hospital than the intervention children. (When possible, we controlled for these characteristics in analyses of the impact of the intervention.) Immunisation coverage, median number of live children, experience of previous child death, and presence of the father in the household were similar in the two groups.

Impact of the intervention
Doctors' counselling performance
One month after training, doctors in the intervention group performed better on all the measured aspects of performance, though observed differences were compatible with chance. Six months after training, the performance of the intervention group on several behaviours had declined substantially (figure).

View larger version (29K): [in this window] [in a new window]   Counselling performance of intervention doctors at one month and six months

 

Mothers' recall of counselling
At the first follow up home visit, mothers were asked about their interaction with the doctor during the consultation. More mothers in the intervention group than in the control group reported that the doctor had explained one or more target signs (table 1). A high proportion reported that the doctor had given them a child health card, and most of them could produce the card.

View this table: [in this window] [in a new window]   Table 1 Mothers' recall, at one month, of counselling by doctors during initial consultation. Values are numbers (percentages) unless otherwise stated

 

Mothers' perceptions of appropriate care
When presented with the three scenarios concerning sick children with danger signs, intervention group mothers indicated more often than control group mothers that they would seek care from an appropriate provider promptly (29% of 3420 scenarios v 12% of 3330 scenarios; P = 0.005).

Careseeking behaviour
During the follow up period, 2851 episodes of child illness were reported by mothers in the intervention group and 2654 in the control group (mean 2.45 in intervention group v 2.38 in control group). In a high proportion of these episodes mothers in both groups reported seeking care outside the home (table 2). Intervention group mothers reported seeking care from an appropriate provider promptly (within 24 hours of recognition of the illness) more often than control group mothers (P = 0.02).

View this table: [in this window] [in a new window]   Table 2 Comparison of intervention and control groups with respect to careseeking behaviour for reported child illness episodes during the six month follow up period. Values are number (percentage) of episodes unless otherwise stated

 

Mothers in both groups reported the presence of one or more danger signs in 19% of all illness episodes. Intervention group mothers perceived 49% (268) of these illness episodes as serious and control group mothers perceived 41% (210) as serious (P = 0.26). Mothers in both groups reported seeking care outside the home in more than 90% of these episodes. A higher proportion of intervention group mothers reported seeking care from an appropriate provider than control group mothers and reported seeking appropriate care promptly.

What is already known on this topic Counselling by trained providers can improve some key family practices for childcare such as feeding Randomised trials to determine whether counselling can also improve care seeking have not been performed What this study adds Training doctors of rural primary health centres to counsel mothers on danger signs and when to seek prompt care can improve the mothers' appreciation of the need to seek care The effect on mothers' careseeking behaviour is limited Educational interventions to improve care seeking for childhood illnesses in different settings should be developed

Discussion

Mothers attending primary health centres in the intervention arm were more likely to recall messages and identify an appropriate course of action for children's illnesses. Responses of mothers in the intervention group to hypothetical scenarios indicates that counselling by trained providers influenced the perceived efficacy of facility based treatment and mothers' knowledge of when to seek care promptly. Evidence that the intervention improved mothers' appreciation of severity is weak.

Previous studies have shown that recognition of illness, perceiving the illness as one that is amenable to treatment at health facilities, appreciating the severity of the illness, and having access to good quality services influence whether caretakers seek appropriate and timely care.^9-12 On the basis of these studies, various strategies have been proposed to improve careseeking behaviour including improving access, educating families to recognise illness and appreciate severity, and improving quality of care.^{13 14} However, few studies have measured the impact of these strategies on caretakers' behaviour.

Why did changes in knowledge and perceptions not translate into greater improvements in practice? Firstly, the intervention had little impact on recognition of illness or of specific danger signs. Secondly, the intervention did not impact on other constraints to seeking care, such as access to and cost of treatment. Thirdly changes in behaviour may require prolonged exposure to the educational messages.

The decline in performance of the intervention group doctors in counselling by the end of the six month study period is of concern. Informal discussions with the doctors indicated that, faced with a variety of field and administrative duties, they have little time for clinical duties and counselling. Some doctors reported that poor organisation of the flow of patients results in patients crowding around them at times, making it difficult to counsel individuals. Achieving sustained changes is likely to require efficient scheduling of field and administrative work in relation to clinical work, and organisation of space and flow of patients in health facilities.

Limitations
We enrolled only mothers and children who had already sought care from a health facility at least once. Families who never seek care at primary health centres might respond differently. In addition, the repeated household visits for data collection may have influenced families' careseeking patterns in both study arms. In areas with higher levels of women's literacy and lower levels of poverty, such an intervention could lead to greater gains. Finally, more frequent exposure to educational messages requires further investigation.

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This is the abridged version of an article that was posted on bmj.com on 20 July 2004: http://bmj.com/cgi/doi/10.1136/bmj.38149.703380.47

The child health card is shown on bmj.com

We thank Rajiv Bahl, AIIMs, New Delhi, for support and advice during all phases of the study; B D Gupta, D R Dabi, and Rajesh Mehta, who helped to adapt the training program; and Harish Chellani and Harish Kumar for conducting the training programme. The district health officials of Udaipur district provided invaluable support in implementing the project. We are grateful for the active interest and cooperation of the participant doctors, who often work in difficult situations, and for the hard work and sincerity of our field and data entry staff. We thank Liam Smeeth for helpful comments on a draft version of this paper.

Contributors: See bmj.com

Funding: Division of Child and Adolescent Health, World Health Organisation, Geneva.

Competing interests: SC received salary support and travel costs from the department of child and adolescent health and development, WHO, to support his involvement in this work.

Ethical approval: Ethical committee of Action Research and Training for Health and WHO Secretariat Committee on Research Involving Human Subjects.

References

1. Sutrisna B, Reingold A, Kresno S, Harrison G, Utomo B. Care seeking for fatal illnesses in young children in Indramayu, West Java, Indonesia. Lancet 1993;342: 787-9.[CrossRef][Web of Science][Medline]
2. D' Souza RM. Role of health seeking behaviour in child mortality in the slums of Karachi, Pakistan. J Biosoc Sci 2003;35: 131-44.[CrossRef][Web of Science][Medline]
3. Reyes H, Perez-Cuevas R, Saleroom J, Tome P, Guiscafre H, Gutienez G. Infant mortality due to ARI: influence of primary care processes. Health Policy Plan 1997;12: 214-23.[Abstract/Free Full Text]
4. Desilva MWA, Wijekoon A, Hornik R, Martines J. Care seeking in Sri Lanka: one possible explanation for low childhood mortality. Soc Sci Med 2001;53: 1363-72.
5. World Health Organization. Technical bases for the WHO recommendations on the management of pneumonia in children at first level health facilities. Geneva: WHO, 1991. (WHO/ARI/91.20.)
6. World Health Organization. Counsel the mother: management of childhood illnesses. Geneva: WHO, 1997.
7. World Health Organization. Breastfeeding counselling: a training course. Geneva: WHO, 1993. (WHO/CDR/93.3, 4,5,6.)
8. World Health Organization, Division of Child Health and Development. Integrated management of childhood illness: adaptation guide. Working draft version 3. Geneva: WHO, 1997.
9. Yoder PS, Hornik RC. Perception of severity of diarrhea and treatment choice: a comparative study of health com sites. J Trop Med Hyg 1994;97: 1-12.[Web of Science][Medline]
10. Goldman N, Pebley AR, Gragnolati M. Choices about treatment for ARI and diarrhoea in rural Guatemala. Soc Sci Med 2002;55: 1693-71.
11. Atakouma DY, Gbetoglo D, Tursz A, Crost M, Agbere A, Assimadi JK. An epidemiological study of health care seeking behaviour by children under the age of 5 years at hospital emergency services in Togo. Rev Epidemiol Sante Publique 1999;47(suppl 2): 75-91.[Medline]
12. Tursz A, Crost M, Kermani S, Reghal M, Grangaud JP. An epidemiological study of health care seeking behaviour of children under 5 years of age in Algeria: what lessons for improving the health care system? Rev Epidemiol Sante Publique 1999;47(suppl 2): 18-37.
13. Herman E, Black RE, Wahba S, Khallaf N. Developing strategies to encourage appropriate care seeking for children with acute respiratory infections: an example from Egypt. Int J Health Plann Manage 1994;9: 235-43.[Medline]
14. Tupasi TE, Miguel CA, Tallo VL, Bagasao TM, Natividad JN, Valencia LB, et al. Childcare practices of mothers: implications for intervention in acute respiratory infections. Ann Trop Paediatr 1989;9: 82-8.[Web of Science][Medline]

(Accepted 13 May 2004)

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