Impact of counselling on careseeking behaviour in families with sick children: cluster randomised trial in rural India
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《英国医生杂志》
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
Correspondence to: P Mohan pmohan@unicef.org
Abstract
Delays in seeking appropriate care, and not seeking care at all, contribute to the large number of child deaths in developing countries.1-4 Existing interventions could prevent many deaths in children if they presented for appropriate and timely care.5 Improving families' careseeking behaviour could contribute significantly to reducing child mortality in developing countries. The World Health Organization estimates that seeking prompt and appropriate care could reduce child deaths due to acute respiratory infections by 20%.6
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.7
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
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 (fig 1). The mean numbers of completed visits were 5.5 in the intervention and 5.6 in the control group.
Fig 1 Flow of participants through trial. PHC=primary health centre
Children in the intervention group were slightly younger than those in the control group (mean 1.26 v 1.44 years) (table 1). 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.
Table 1 Baseline social, economic, family, and demographic characteristics. Values are numbers (percentages) of children unless stated otherwise
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 (table 2). They counselled the mothers more often concerning feeding and careseeking and asked open ended questions to check their understanding more often than doctors in the control group. They also seemed to perform better with respect to other aspects of communication, though observed differences were compatible with chance. Six months after training, the performance of the intervention group on several behaviours had declined substantially (fig 2).
Table 2 Communication and counselling performance of doctors one month after training. Values are numbers (percentages) of doctors unless stated otherwise
Fig 2 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 3). A high proportion reported that the doctor had given them a child health card, and most of them could produce the card.
Table 3 Mothers' recall, at one month, of counselling by doctors during initial consultation. Values are numbers (percentages) unless otherwise stated
Mothers' perceptions of appropriate care
At the first follow up visit, mothers were also presented with three scenarios concerning sick children with danger signs, and asked to indicate what they would do in such circumstances. 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 4). In about half of all episodes, the child was reported to have been taken to the primary health centre or another appropriate provider. 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).
Table 4 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 543, control group 513). 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 (65% (353) v 57% (290); P = 0.03) and reported seeking appropriate care promptly (15% (84) v 10% (51); P = 0.07).
Discussion
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.
D' Souza RM. Role of health seeking behaviour in child mortality in the slums of Karachi, Pakistan. J Biosoc Sci 2003;35: 131-44.
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.
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.
Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003;362: 65-71.
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.)
World Health Organization. Counsel the mother: management of childhood illnesses. Geneva: WHO, 1997.
Government of Rajasthan. Rajasthan human development report—2002. Jaipur: Government of Rajasthan, 2002.
World Health Organization, Division of Child Health and Development. Integrated management of childhood illness: adaptation guide. Working draft version 3. Geneva: WHO, 1997.
World Health Organization. Breastfeeding counselling: a training course. Geneva: WHO, 1993. (WHO/CDR/93.3, 4,5,6.)
WHO/CHD Immunisation Linked Vitamin A Supplementation Study Group. Randomised trial to assess benefits and safety of vitamin A supplementation linked to immunisation in early infancy. Lancet 1998;352: 1257-63.
Diehr P, Martin DC, Koepsell T, Cheadle A. Breaking the matches in a paired t-test for community interventions when the number of pairs is small. Stat Med 1995;14: 1491-504.
Miettinen O. Estimability and estimation in case-referent studies. Am J Epidemiol 1976;103: 226-35.
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.
Goldman N, Pebley AR, Gragnolati M. Choices about treatment for ARI and diarrhoea in rural Guatemala. Soc Sci Med 2002;55: 1693-71.
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.
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.
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.
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.
Simoes EAF, Desta T, Tessema T, Gebresellassie, Dagnew M, Gove S. Performance of health workers after training in integrated management of childhood illness in Gondar, Ethiopia. Bull World Health Org 1997;75(suppl 1): 43-53.
Santos I, Victora CG, Martines J, Goncalves H, Gigante DP, Valle NJ, et al. Nutrition counseling increases weight gain among Brazilian children. J Nutr 2001;131: 2866-73.(Pavitra Mohan, coordinato)
Correspondence to: P Mohan pmohan@unicef.org
Abstract
Delays in seeking appropriate care, and not seeking care at all, contribute to the large number of child deaths in developing countries.1-4 Existing interventions could prevent many deaths in children if they presented for appropriate and timely care.5 Improving families' careseeking behaviour could contribute significantly to reducing child mortality in developing countries. The World Health Organization estimates that seeking prompt and appropriate care could reduce child deaths due to acute respiratory infections by 20%.6
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.7
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
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 (fig 1). The mean numbers of completed visits were 5.5 in the intervention and 5.6 in the control group.
Fig 1 Flow of participants through trial. PHC=primary health centre
Children in the intervention group were slightly younger than those in the control group (mean 1.26 v 1.44 years) (table 1). 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.
Table 1 Baseline social, economic, family, and demographic characteristics. Values are numbers (percentages) of children unless stated otherwise
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 (table 2). They counselled the mothers more often concerning feeding and careseeking and asked open ended questions to check their understanding more often than doctors in the control group. They also seemed to perform better with respect to other aspects of communication, though observed differences were compatible with chance. Six months after training, the performance of the intervention group on several behaviours had declined substantially (fig 2).
Table 2 Communication and counselling performance of doctors one month after training. Values are numbers (percentages) of doctors unless stated otherwise
Fig 2 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 3). A high proportion reported that the doctor had given them a child health card, and most of them could produce the card.
Table 3 Mothers' recall, at one month, of counselling by doctors during initial consultation. Values are numbers (percentages) unless otherwise stated
Mothers' perceptions of appropriate care
At the first follow up visit, mothers were also presented with three scenarios concerning sick children with danger signs, and asked to indicate what they would do in such circumstances. 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 4). In about half of all episodes, the child was reported to have been taken to the primary health centre or another appropriate provider. 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).
Table 4 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 543, control group 513). 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 (65% (353) v 57% (290); P = 0.03) and reported seeking appropriate care promptly (15% (84) v 10% (51); P = 0.07).
Discussion
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.
D' Souza RM. Role of health seeking behaviour in child mortality in the slums of Karachi, Pakistan. J Biosoc Sci 2003;35: 131-44.
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.
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.
Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003;362: 65-71.
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.)
World Health Organization. Counsel the mother: management of childhood illnesses. Geneva: WHO, 1997.
Government of Rajasthan. Rajasthan human development report—2002. Jaipur: Government of Rajasthan, 2002.
World Health Organization, Division of Child Health and Development. Integrated management of childhood illness: adaptation guide. Working draft version 3. Geneva: WHO, 1997.
World Health Organization. Breastfeeding counselling: a training course. Geneva: WHO, 1993. (WHO/CDR/93.3, 4,5,6.)
WHO/CHD Immunisation Linked Vitamin A Supplementation Study Group. Randomised trial to assess benefits and safety of vitamin A supplementation linked to immunisation in early infancy. Lancet 1998;352: 1257-63.
Diehr P, Martin DC, Koepsell T, Cheadle A. Breaking the matches in a paired t-test for community interventions when the number of pairs is small. Stat Med 1995;14: 1491-504.
Miettinen O. Estimability and estimation in case-referent studies. Am J Epidemiol 1976;103: 226-35.
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.
Goldman N, Pebley AR, Gragnolati M. Choices about treatment for ARI and diarrhoea in rural Guatemala. Soc Sci Med 2002;55: 1693-71.
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.
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.
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.
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.
Simoes EAF, Desta T, Tessema T, Gebresellassie, Dagnew M, Gove S. Performance of health workers after training in integrated management of childhood illness in Gondar, Ethiopia. Bull World Health Org 1997;75(suppl 1): 43-53.
Santos I, Victora CG, Martines J, Goncalves H, Gigante DP, Valle NJ, et al. Nutrition counseling increases weight gain among Brazilian children. J Nutr 2001;131: 2866-73.(Pavitra Mohan, coordinato)