Health care seeking behavior and associated factor among mothers/caregivers of under-five children with acute diarrhea in Dangila zuria Woreda, North west Ethiopia

Introduction Health care seeking interventions can reduce child mortality from easily treatable diseases, however, significant numbers of children die by diarrheal disease due to delays in seeking care in Ethiopia. Thus, the aim of this study was assessed health care seeking behavior and associated factors among mothers/caregivers of under-five children with acute diarrhea in Dangila zuria Woreda, North West Ethiopia, 2018. Method Community-based cross-sectional study design was conducted using structured questionnaires. Data were entered Epi Data Version 3.1 and analyzed using SPSS Version 23. Descriptive statistics were used to examine patterns of health care seeking behavior and multivariable logistic regression analysis was applied to identify factors associated with health care seeking behavior Result The magnitude of health care seeking behavior of mothers/caregivers of under-five children with acute diarrhea was found to be 77.7%. Primary level of education [AOR = 2.0; 95% (CI (1.1-3.9)], sex of child (male) [AOR = 1.7; 95% (CI 1.1-2.6)], availability of health facilities within 60 minutes walking distance [AOR = 2.4; 95 %(CI 1.4-4.1)], severity of illness [AOR=7.5; 95% (CI 3.7-15.2)], two or more under-five children in the family [AOR=0.6;95% (CI 0.4-0.9)], perceived cause of acute diarrhea, (new teeth [AOR =0.3;95% (CI 0.2-0.5)] were significantly associated with health care seeking behavior of mothers/caregivers. Conclusion Increasing the proximity of health facilities and educate mothers/caregivers about the importance of health care seeking behavior and cause of acute diarrhea were recommended to improve health care seeking behavior.


Introduction
Health-seeking behavior has been defined as a sequence of remedial actions that individuals undertake to rectify perceived ill-health. It is the process of care seeking by individuals for improving the perceived disease and it is a reflection of the prevailing conditions, which interact synergistically to produce a pattern of care seeking but which remains fluid and therefore amenable to change (1).
Although under-five mortality has been reduced globally, diarrhea is the first leading cause of under-five children mortality in the world (2) and the situation in sub-Saharan Africa is still a major concern(3). Sub-Saharan Africa (SSA) has made the least progress in terms of reduction of child mortality compared to all other regions in the world (4). Health care seeking interventions have the potential to reduce child mortality, however, in developing countries, a large number of children die without ever reaching a health facility and (5).
World Health Organization reported that 70% of child deaths are related to delayed care-seeking (6). A study done in Nairobi, Kenya showed that healthcare-seeking practices for diarrhea remain great challenges and more than half (55%) of the caregivers seeking inappropriate health care with a large number of caregivers (35%) taking no action regarding the child diarrheal (7). Similarly, a study done in Tanzania indicated that only 23.0 % of children with acute diarrhea treated at a health facility (8).
Poor health care seeking behavior increases the chance of morbidity and mortality of children (9). Significant numbers of children die due to delays in seeking care in Ethiopia (10). For instance, a study done in Bahir Dar city indicated that diarrhea was higher in under-five children but treatment seeking was low due to low seeking behavior of mothers (11).
In the study area, the woreda Health Management Information System (HMIS) report indicated that, among expected diarrheal cases, only 27% of under-five children were treated in 2017 (12). However, factors to hinder health care seeking were unknown.
Even if, little studies were conducted in Ethiopia regarded health care seeking behaviors for acute diarrhea, previous studies were not community-based and disease-specific. Therefore, the aim of this study was to assess health care seeking behavior and associated factors among mothers/caregivers of under-five children with acute diarrhea in Dangila Zuria Woreda, North West Ethiopia, 2018. This study might help program planners and implementers to design intervention pertaining to health care seeking behavior promotion, to treat diarrhea disease of under-five children and to this study may use as baseline for researchers.
There are two major frameworks that have been proposed to explain the health care services utilization of an individual from the behavioral aspect. These are Andersen & Newman model and the Kroeger's model (13).
Andersen's health behavior model is common and used to study the determinants of health care seeking behavior. We used this model as a conceptual framework for our analyses (14).
According to Andersen's behavioral model, predisposing, enabling, and need factors at the individual and community levels are instrumental for increasing health-seeking behavior and health facilities utilization.
Predisposing factors were reflecting the families which are likely to use health services while enabling factors are those which promote or hinder health service use. The first two sets of factors are not enough until the family perceives the severity of the illness. This is called as 'need' factor which is the most immediate reason for health service use (15,16). Inappropriate health care seeking behavior increases the chance of morbidity and mortality of children. So to improve the health of under-five age children, the health care seeking behavior of mothers/caregivers plays a major role in determining the infant's survival (9).  (17).

Study Period and Population
The study was conducted from November 1,2018 to December 1,2018. The source populations were all mothers/caregivers who had under-five children with acute diarrhea in the last 2 weeks of the preceding data collection period in Dangila Zuria Woreda.
Study Population Randomly selected mothers/caregivers from 10 kebeles who had under five children with acute diarrhea in the last 2 weeks of data collection period in Dangila Zuria Woreda.

Inclusion and Exclusion Criteria
Inclusion Criteria all mothers/caregivers who had under-five children (1-59 months) with acute diarrhea in the last 2 weeks of data collection period and resided for at least 6 months in the study area.
Exclusion Criteria Mothers/caregivers who can't communicate due to severe illness or sickness.

Sample Size Determination
For sample size estimation, we assumed a 95% confidence interval (CI), a margin of error of 5%, a proportion of 56 % for health care seeking conducted nationally in four region of rural Ethiopia (Amhara ,SNNP, Oromia and Tigray) (18), and a design effect of 1.5. As the source population was less than 10,000; sample size correction was performed. Then, 10% non-response rate was added to obtain the enough sample size n= (zα/2)2 p (1-p)/d2= 378 n = required sample sizes When we consider the design effect (1.5), the sample size required became: For possible nonresponse during the survey the final sample size is increased by 10% to n = 567 +10% which is 57 = 624. Therefore, the total sample size including 10% NRR was 624.

Dependent variables:
Health care seeking behavior

Sampling procedure
A total of 10 kebeles were included in the study, one kebeles in urban and 9 kebeles in rural were selected using the lottery method. Then systematic random sampling was employed to selected households after allocating the number of under-five children with acute diarrhea in each kebele proportionally. The first household was chosen near the Kebele Council as a starting point. Households with no under five children with acute diarrhea were excluded from the study. After a successful interviewee of each household the interviewer continue to the right side of the next household whenever there is more than one under five children with acute diarrhea in a household only one was selected using lottery method and all caregivers in the selected kebele that full fill the sampling criteria are interviewed until the required sample size was reached.

Operational definition
Modern health care seeking behavior: Is care sought from health facilities; hospitals, health centers, private clinics or health posts for under-five children with acute diarrhea within 2 weeks (10).
Acute diarrhea: The passage of three or more abnormally loose watery or liquid stools over 24 h periods within 2 weeks prior to the data collection.
The severity of illness: Was identified simply according to mothers /caregiver's perception of the disease condition.

Data collection procedures and data quality control
Data were collected using questionnaires and carried out by face to face interview method. Data collectors and supervisor were coming from other non-selected and trained for two days on objectives, interview method, confidentiality, and data quality control. Two BSC nurses as the data collectors and one health office as the supervisor have participated. Firstly, the questionnaire was designed in English and translated into local Amharic language by language expert then translated into English for the consistency of the questionnaire. The pre-test was conducted on 5% of the sample size. After pre-testing further adjustments to the data collection tool was made to improve the clarity, understandability, and simplicity of the messages.
Check the completeness of questionnaires page by page before and after the data collection were conducted.
When the data were collecting supervise consecutively each data collectors and prepare regular meetings each day. The interviewed questionnaires were reviewed, collected and checked by the supervisor and principal investigator daily.

Data processing and analysis
Data were entered Epi Data Version 3.1 and analyzed using SPSS Version 23. The data were checked for completeness and cleaned for the errors during data entry. Descriptive statistics were used to examine patterns of health care seeking behavior and multivariable logistic regression analysis was applied to identify factors associated with health care seeking behavior. Finally, 95% confidence interval and a p-value less than 0.05 was considered as significant associated factors of health care seeking behavior.

Ethical considerations
Ethical clearance was obtained from Institutional Review Board committee of Bahir Dar University college of Medicine and health sciences.
Then ethical approval letter was taken to the respective health facility managers and kebele administrators and written consent was obtained from participants after informing of the confidentiality of the information they give and will not be given to anyone without their consent. The name of participant did not document in the questionnaire. The participants will have as full right to withdraw from study at any time during interview.

Socio demographic characteristics of respondents and children
In this study, 624 mothers/caregivers who had under-five years' old children with acute diarrhea were interviewed with a response rate of 100%. Six hundred five (97%) were mothers of the selected child, 229 (37%) in the age group of above 35 years with a mean age of 32 and 554 (88.8%) were married. Regarding sex and age of the child, 51% of children were males and 35% of children were in the age group of 12 to 24 months. (Table 1).

Reasons for not seeking care at the health facility
Among the reasons for not seeking health facilities, 72% of mothers/caregivers were not seeking care for their child due to illness was not sever and 36% were due to mothers/caregivers were busy. Among privet health facility utilizer, 60% of mothers/caregivers prefer private health facility due to treatment obtained within a short period of time (Table 2).  Those mothers/caregivers who had a male child were more likely to have health care seeking behavior of under-five children with acute diarrhea compared to those who had a female child. (AOR = 1.7; 95% CI (1.1-

2.6))
Those mothers/caregivers who had 2 or more under-five children in the family were 40% less likely to have health care seeking behavior compared to those who had one under five child in the family with acute diarrhea (AOR=0.6;95% CI (0.4-0.9)).
Those mothers/caregivers who had the educational levels of primary school were two times higher than those who were illiterate to have health care seeking behavior of under-five children with acute diarrhea (AOR = 2.0;95% CI (1.1-3.9)).
Those mothers/caregivers who had severely ill children according to their perception were nearly seven and half times higher than those who were not severely ill to have health care seeking behavior for under fivechildren with acute diarrhea (AOR=7.4; 95% CI (3.7-15.2)) Those mothers/caregivers who perceived new teething as the cause of acute diarrhea were 70 % less likely to have health care seeking behavior of under-five children with acute diarrhea as compared to those who did not perceive new teething as the cause of acute diarrhea (table 3).  (10), and lower than the study conducted in the Gambia of Ethiopia (81.5%) (19) this might be due to the difference in geographic and socioeconomic conditions.
The magnitude of health care seeking behavior of this study was higher than the study conducted at the national level of Ethiopia (56%) (18), and in Addis Abeba (56.6%) (20). This difference might be due to seasonal variation.
In terms of sex preference in healthcare-seeking behavior, the study shows a significant difference between male and female children, a male child is 1.7 more likely to seek health care than female children. A number of studies has shown boys preference in seeking health care especially for childhood illnesses like acute diarrhea (21)(22)(23). The likely explanation for the difference in seeking treatment differently for boy and girl children could be due to cultural effect and gender inequality that cause disadvantages females in the community, which in turn, may impose mothers/caregivers to give priority to a boy child.
Those mothers who have more than or equal to two number of under-five children in the family members were 40% less likely to seek medical care than those who have one under-five child in family members, contrary to our finding, study done in Addis Ababa indicated that there was no difference in health care seeking behavior of mothers/caregivers of under-five children with acute diarrhea due to number of under-five children in the family (20). This might be due to the incapability of the mothers/caregivers to care for many under-five children and a shortage of money for seeking care in the study area as compared to Addis Ababa mothers/caregivers.
In this study, the relationship between the educational level of the respondents (primary level of education) and health care seeking behavior was found to be statistically significant. Which is consistent with studies done in Nigerian, Nepal, and Ensaro district North Shoa Zone (24)(25)(26). This is because educated mothers/caregivers can understand health education messages presented in mass media and through other methods more than the none educated ones.
Another finding from this research is that proximity to the health facility within 60 minutes walking time has significantly associated with the health-seeking behavior of the mother caregiver.
This is similar to other studies done in the Oromia region (22,27). This is because living far away from the location of health facility may force mothers to walk or travel long distance which could lead to tiredness, exposure to hazard or incurring more expenses. Due to this, the mothers might be discouraged from presenting their children for medical treatment.
In the current study, mothers who perceived illness was sever were seven times more likely to seek medical care than those who perceive the illness is not severed. This finding is similar to a study done in Mekele city (28). This may be due to the mother's belief of illness will improve by itself and wait until their child shows another symptom. So, this could be an indicator of as mothers are being heath seeker while their child is seriously ill.
We found that the perceived cause of acute diarrhea (new teething) decreases the likelihood of seeking care. Contrary to this finding, some studies reported that the perceived cause of acute diarrhea was not a reliable predictor of care seeking by mothers/caregivers( (20,29). It might be due to cultural and socio-demographic differences.

Limitations;
The study utilized perception and oral report of an individual for health care seeking report which may be increase the magnitude of health seeking behavior. Qualitative study was not done to triangulate it.

Conclusion and recommendations
Even if many mothers/caregivers of under-five children with acute diarrhea sought health care

ACKNOWLEDGEMENT
First and for most, we would like to forward the deepest appreciation and thanks to Dangila Zuria Woreda health office and Health Extension Workers for their valuable information provided to us .Our special appreciation go to study participants, data collectors, and supervisors, and also we