Knowledge, Attitude and Practice of mothers on acute respiratory infection in children under five years

Objective: To assess Knowledge, Attitude and Practices of mothers on ARI (Acute Respiratory Tract Infection) in children less than five years of age. Methods: This cross-sectional survey was conducted in the Department of Pediatrics, Darul Sehat hospital from 1st December 2014 to 28th February 2015. Mothers(n=335) who were local residents, had at least one child below the age of five years and coming to the hospital for any medical problem along with accompanying women were included. Foreign mothers and/or those having difficulty in perceiving questions were excluded. Language used in the Questionnaire was English which was translated to Urdu for better understanding. Questionnaire was interviewer administered. Researchers and two house physicians took part in questioning the mothers. Results: Total 335 children were studied. Out of 335 children 228(68%) had ARI. Mean age of the children was 20 months ±17 SD while mean Birth weight was 2.7 kg ± 1.8 SD. The most common symptom perceived was cough (n=303, 40%), mostly worsening during winter season (n=255,87%), commonest aggravating factor was dust (n=174,81%), most common complication was Pneumonia (n=135, 83%), and most mothers opted for medical practitioner (n=268,89%) for treatment. Self-medication was practiced by 192(58%) and paracetamol was frequently used medication (n=117,42%). Conclusion: The study reveals good knowledge of mothers on ARI symptoms, worsening environmental conditions, aggravating factors and complications. Their attitude towards ARI was appropriate with early consultation with qualified medical practitioner. Better literacy rate, has a positive influence on the Knowledge, Attitude and Practices of mothers.


INTRODUCTION
Acute Respiratory Infection (ARI) is considered as one of the leading causes of morbidity and mortality in children and it incurs upon high economic cost. It is the main reason for utilization of health services for children. Its control is a big public health concern especially in developing countries. It constitutes Upper Respiratory Infection (URI) and Lower Respiratory Infection (LRI). Upper respiratory infection presents mainly with Rhinitis (Common Cold), Tonsillitis, Sinusitis and ear infection while main presentations of LRI is Pneumonia which exhibits with increased respiratory rate.

Original Article
Knowledge, Attitude and Practice of mothers on acute respiratory infection in children under five years All over the world, average ARI experience of child is 6-8 spells in a year. 1 The incidence of ARI in Pakistan is 16% as shown by a survey conducted in Pakistan in 2011. 2 That survey also revealed that ARI was more prevalent in urban areas in the country. Over the counter (OTC) drugs are frequently administered by parents to their children as ARI causes discomfort and distress to the parents. Proven efficacy of such drugs is lacking. 3 Also these could be hazardous 4 and have not been endorsed by Food and Drug Administration (FDA) 5 and American Academy of Pediatrics. 6 In such conditions safe home remedy and proper care are mainly recommended.
In developing countries, awareness regarding knowledge attitude and practices of mothers in acute respiratory tract infection (ARI) needed evaluation so researchers endeavored to get base line data for better understanding of the magnitude of problem. That will add to the existing pool of knowledge on ARI. The objective of the study was to assess knowledge, attitude and practices of mother's on ARI(Acute Respiratory Tract Infection) in children less than five years.

METHODS
This cross-sectional survey was conducted in the Department of Pediatrics, Darul Sehat hospital, Karachi from December 01, 2014 till February 28, 2015 as there is more reported cases of ARI during winter season in our hospital. It was non probability purposive sampling. Keeping incidence of ARI 16%, CI 95% and absolute precision required 0.05, minimum sample size came out 204. Inclusion criteria: Mothers who opted to participate in the study. Mothers who had at least one child below the age of five years and who came to the hospital for any of their child's disorder. Mothers coming to the hospital for any of their medical problem. Women who were accompanying them and had at least one child less than five years of age Exclusion criteria: Mothers unable to perceive questions. Mothers who are foreigner to the local area.
Permission was taken from the Ethical Review Committee. Study protocol was approved by Ethical Review Committee of Liaquat College of Medicine & Dentistry on 10 th November 2014. Verbal informed consent was taken from the mothers. Their autonomy, confidentiality and anonymity were maintained. They had complete liberty not to response to any of the questions and quit at any time during the study. That act would, in no way, affect their due care in the hospital. Data collection procedure: Language used in the Questionnaire was English which was translated to Urdu for better understanding. Questionnaires were interviewer administered. Researchers and two house physicians took part in questioning the mothers. The researchers scrutinized these filled questionnaires. Main Independent variables included gender, birth weight and mothers education. The main dependent variables were knowledge of mothers on symptoms of ARI, disease aggravating and worsening factors and complications of the disease. Education, occupation, parity of the mothers, socioeconomic status and family type were categorical variables. Practicing self-medication, type of self-medication and consulting qualified persons for the disease were also dependent variables. Data analysis: SPSS-16 was used. For birth weight mean and standard deviation while for other independent and categorical variables frequencies were calculated. Missing data on child birth weight was 18% and was replaced with series mean.

RESULTS
Total 335 mothers were interviewed. Out of 335 children 228(68%) had ARI. Two hundred sixty five (81%) of mothers acquired higher than secondary education (Table-I). Two hundred ninety six (92%) mothers were house wives and 216 (66%) mothers had less than two children .Mean age of the children was 20 months ±17 SD while that of the mothers was 29 years ± 4 SD. Mean birth weight of the children was 2.7 kgs ±1.8 SD. Mean duration of ARI was five days (SD2.1). Two hundred twenty (85%) had monthly earning of > Rs.20, 000/m. Joint family system constituted 201 (62%) and 325 (99%) of the children were delivered at hospital. Fully vaccinated children by EPI were 309 (94%) while 261 (80%) were vaccinated against Pneumonia (Table-I). Only 36 (11%) of the children were suffering from under nutrition and 229 (69%) were breast fed (Table-I).

DISCUSSION
Mothers were interviewed in this study because mostly mothers accompany their children to hospital. 7,8 Most of the mothers had less than two children. The study showed an overall literacy rate of mothers being 97%. Of these, 80% were higher than secondary education. This is in comparison to a similar study 9 conducted at Tharparkar showing overall literacy rate of mothers being 74% with urban background. Both the studies are showing higher level of education in mothers as they are having urban background and this fact lays emphasis that the government should make efforts to increase the level of education in mothers   in rural areas. Literate mothers are more vigilant in seeking medical care for their children. Immunization coverage of children by EPI in this study was 94% where as it is 85% as shown by a study conducted in Kenya. 10 This study showed that 69% of the children with ARI were continued breast feeding while in another study it was 65%. 11 In this study 36 (11%) of the children was suffering from under nutrition while in a study conducted in Nepal 12 it was 23 (38%). This finding stresses upon the concerned authorities to start health programs regarding nutrition of children. Such programs are likely to be successful as literacy rate of mothers is high and they mostly belong to working class.
The most common symptom of ARI found in this study was Cough (40%). Other symptoms in order of frequency were Fever (34%), Wheeze (9%), Sneezing (12%) and ear ache (5%) where as in a study carried out in Ghana the common symptoms were retraction of ribs (22%), fever cough and lethargy (57%) 13 In a study conducted in Dar us Salam major symptoms were Fever (92.5%), Cough (85.3%) and inability to play (83.5%). 14 The mean duration of ARI in this study was five days (SD2.1) which is in contrast to a study conducted by Shahzad Munir 11 showing mean of 4.5 days (SD-3.1). This low mean duration of the illness could be due to the fact that 317 (94%) mothers consulted qualified medical practitioner for ARI where as in a study conducted in Tehran 15 , 141 (62%) mothers preferred medical practitioner.
In this study 8% of the mothers believed that antibiotics were necessary for ARI. In other studies higher incidence of use of antibiotic has been reported by Chan et al. 16 (68%) and Bhanwra et al. 17 (46%). These are contradictory to our findings as mothers are more literate having better awareness about the hazards of using unnecessary antibiotics. Studies conducted by Farhad et al. 18 showed use of antibiotics 5% and Panagakau et al. 19 10%. These percentages are similar to study in hand. Less use of antibiotic in this study is a healthy sign showing that mothers are well aware of this important issue.
Use of self medication was found 58% in this study. Similar picture was shown by a study conducted in Multan 20 where it was 58%. The self medication used in this study includes paracetamol and ibuprofen which is extremely common and the mothers think that such drugs are harmless and could safely be given. Such drugs are over-thecounter class of drugs and that routinely used as self-medication reason being less harm full.
Home remedies were practiced by 6% of the participants in the current study. Other studies conducted in, Multan 20 and Lahore 21 demonstrate practice of home remedies as 40% and 23% respectively. Joshanda use was 4% of the self medication. In a study conducted in New Delhi 22 the use of Ginger as home remedy in ARI in children was 27%. This could be due to cultural difference. Dust was the most common aggravating factor of the disease (81%) while in a study conducted in Myanmar it was 89%. 23 This finding could be due to the general environmental condition of area and low municipality services.

CONCLUSION
Knowledge of mothers on ARI symptoms, worsening environmental conditions, aggravating factors and complications was found satisfactory. Their attitude towards ARI was appropriate with early consultation with qualified medical practitioner. Better literacy rate, has a positive influence on the Knowledge, Attitude and Practices of mothers.

Declaration of interest:
The authors declare no conflict of interest with regard to research, authorship and publication of the study.