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Mothers’ Socioeconomic Differentials and Management of Malaria in Nigeria:

Mothers’ Socioeconomic Differentials and Management of Malaria in Nigeria: About 150 million Nigerians live in areas of intense malaria transmission. Malaria has the greatest prevalence, close to 50% in children aged 6 to 59 months. A review of literatures revealed that more than 80% of malaria episodes received treatment outside of the existing government health care system. This means that treatments are rarely sought at health care facilities and are most often inappropriate or delayed. Reasons underlying these practices range from mothers’ socioeconomic status to difficulty in accessing health care facilities. Therefore, this study re-examined whether mothers’ socioeconomic characteristics and barriers to access health care facilities are major factors that influence mothers’ choice of treatment and delays in seeking treatment of malaria among under-five children in Nigeria. The study used Nigeria Demographic and Health Survey kids recode dataset. The data were analyzed using STATA 12 software. The result showed significant relationship 2 2 2 between religion (χ = 216.24, p < .05), education (χ = 257.55, p < .05), occupation status (χ = 21.88, p < .05), wealth index 2 2 2 (χ = 207.08, p < .05), type of residence (χ = 18.56, p < .05), region of residence (χ = 350.82, p < .05), and type of treatment sought and delay in seeking treatment for malaria. Also, the likelihood of seeking medical and prompt treatment among mothers with four different barriers is significantly less (odds ratio = 0.53; p < .05; 95% confidence interval = [0.38- 0.75]), when compared with their counterparts without any barrier. The study concluded that mothers` socioeconomic status and access to health care facilities must be improved to ensure appropriate and prompt use of health care facilities for treatment of malaria among under-five children in Nigeria. Keywords social sciences, under-five, mortality, demographics, early childhood, education, socioeconomic, childhood, malaria, Nigeria South-West, North-Central, and North-West regions while it Introduction has the least prevalence, 27.6%, in children aged 6 to 59 Malaria poses a major public health challenge as the third months in the South-East region (USAID/PMI, 2011). leading cause of death among under-five children world- According to studies, an estimated one in five child deaths is wide. About 3.3 billion people are affected by malaria, due to malaria, which accounts for more than 300,000 deaths almost half of the world’s population, in 106 countries and among under-five children every year. It is also believed to territories. World Health Organization (WHO) estimates that contribute up to 11% maternal mortality, 25% infant mortal- 216 million cases of malaria occurred in 2010, 81% in the ity, and 30% under-five mortality in Nigeria. In addition to African region that resulted in 655,000 malaria deaths in the direct health impact of malaria, there are also severe 2010, and 86% were children under 5 years of age (WHO, social and economic burdens on communities and the coun- 2010). Thirty countries in sub-Saharan Africa account for try as a whole, with about 132 billion Naira lost to malaria 90% of global malaria deaths. Nigeria, Democratic Republic annually in the form of treatment costs, prevention, loss of of Congo (DRC), Ethiopia, and Uganda account for nearly work time, and so on (Federal Ministry of Health, 2009). 50% of the global malaria deaths. Malaria is the second lead- As part of the child survival strategy, WHO and United ing cause of death from infectious diseases in Africa, after Nations Children’s Emergency Fund (UNICEF), in 1995, HIV/AIDS, and the third leading cause of death for children after pneumonia and diarrheal disease worldwide (U.S. Agency for International Development [USAID]/ President’s 1 Obafemi Awolowo University, Ile-Ife, Nigeria Malaria Initiative [PMI], 2011). Association for Reproductive and Family Health, Ibadan, Nigeria About 150 million Nigerians—almost the entire popula- Corresponding Author: tion of the country—live in areas of intense malaria trans- Ojewumi Titus Kolawole, Obafemi Awolowo University, Ile-Ife, Osun, mission (WHO, 2008). Malaria has the greatest prevalence, Nigeria. close to 50%, in children aged 6 to 59 months in the Email: ojetitus1@gmail.com Creative Commons CC-BY: This article is distributed under the terms of the Creative Commons Attribution 3.0 License (http://www.creativecommons.org/licenses/by/3.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 SAGE Open intensified effort and initiated the Integrated Management of care could reduce child deaths due to malaria, diarrhea, and Childhood Illnesses (IMCI) to assist developing countries acute respiratory infections by 20% (WHO, 1999). However, reduce childhood mortality caused by most childhood killer there are controversial findings on whether the use of mod- diseases: diarrhea, acute respiratory infections, malaria, ern health services is often influenced by individual percep- measles, and malnutrition.(WHO/UNICEF, 1997). Malaria tions of the efficacy of modern health services, religious control activities in Nigeria are planned and implemented beliefs, residence, occupation, place of delivery, wealth sta- through the primary health care (PHC) system (WHO, 2006). tus, level of education, and so on (Adetunji, 1996; Adeyemi, The strategy used for the implementation of the national anti- 2000; Ene-Obong, Uwaegbute, Iroegbu, & Amazigo, 1998; malarial treatment policy is that of Roll Back Malaria (RBM). Fapohunda & Beth, 2004; Hill, Kendall, Arthur, Kirkwood, The RBM strategy for the control of malaria has as one of its & Adjei, 2003; Mekonnen & Mekonnen, 2002; Pate, 2001; key elements that patients with malaria should have access to Sabitu, 2004; United Nations Population Fund [UNFPA], appropriate and adequate treatment within 24 hr of the onset 2002, 2004). Therefore, this article examined the influence of symptoms. However, the use of health care facilities as the of mothers’ socioeconomic characteristics and barriers to first resort for malaria and treatment/management has been access health care facilities on mothers’ choice of treatment shown to be low in many African countries, including and delays in seeking treatment of malaria among under-five Nigeria. Treatments are rarely sought at health care facilities children in Nigeria. and are most often inappropriate or delayed (Guyatt & Snow, 2004; Kofoed, Rodrigues, Hedegaard, Rombo, & Aaby, Research Questions 2004; Müller, Traore, Becher, & Kouyate, 2003). Less than 15% of the malaria episodes treated at home is treated cor- Against the above background, the fundamental questions rectly. Most fevers in children are treated with simple fever that readily come to mind are as follows: drugs, such as paracetamol and aspirin, but not with anti- malarial drugs. Even when anti-malarial drugs are purchased, Research Question 1: Do mothers’ socioeconomic char- they are commonly administered in inappropriate doses acteristics (age, level of education, occupation, religion, (WHO, 2004). wealth index, etc.) have significant influence on type of A review of mothers’ malaria treatment-seeking behavior treatment sought and prompt treatment of febrile illness? in Nigeria revealed that more than 80% of malaria episodes Research Question 2: Does barrier in accessing health received treatment outside the existing government health care facilities have any influence on type of treatment and care system (Ajayi & Falade, 2006; Olaogun, Ayandiran, prompt treatment of malaria? Olasode, Adebayo, & Omokhodion, 2005). Reasons under- lying these practices range from maternal literacy and health Method education, socioeconomic status, difficulty in accessing health care facilities, attitude of health personnel, cultural Data Collection Method beliefs on the ease of use of traditional herbs, and support for The Nigeria Demographic and Health Survey (NDHS) kids treatment offered by other household members (Feyisetan, recode data set was used for this study. The survey was cross- Asa, & Ebigbola, 1997; Mermert & Nsabagasanyi, 2002; sectional. It was designed to provide specific information on Namusobya, 1998; Pérez-Cuevas, Guiscafré, Romero, population and health indicators at the national, zonal, and Rodríguez, & Gutiérrez, 1996; WHO/UNICEF, 2003). state levels. Information collected includes birth histories, These shortcomings encourage treatment of malaria at in-depth demographic and socioeconomic information on ill- home with drugs bought from shops and herbal preparations nesses, medical care, immunizations, and anthropometric (Baume, Helitzer, & Kachur, 2000; Pérez-Cuevas et al., details of children (National Population Commission [NPC] 1996; Salako et al., 2001). “These treatments are usually [Nigeria] & ICF Macro, 2009). Therefore, from the sampling incorrect or sub-optimal” (Brieger, Osamor, Salami, Oladepo, frame of 33,385 of all married women interviewed in Nigeria, & Otusanya, 2004; Jimmy, Achelonu, & Orji, 2000). Mothers 18,028 women with at least a child aged 12 to 59 years were and caregivers only usually visit a health centre or hospital extracted, out of which 3,068 women whose child has had at after the illness has failed to respond to several drugs and least an history of malaria episode in the last 2 weeks before ineffective self-treatment. These practices increase morbid- the survey were extracted for this study having applied the ity and mortality in addition to contributing to possible emer- weighting factor. gence of drug resistance among under-five children in Nigeria (Okonkwo, Akpala, Okafor, Mbah, & Nwaiwu, 2001; WHO/UNICEF, 2003). Data Analysis Meanwhile, studies have shown that existing interven- tions could prevent many deaths among children if they are Having obtained the data set and extracted the eligible presented for appropriate and timely care (Jones et al., 2003). respondents, the data were analyzed using STATA 12 soft- The WHO estimates that seeking prompt and appropriate ware. The analysis involved three stages. The first stage is Kolawole and Asaolu 3 univariate analysis, at this stage, mothers’ background char- (prompt) of onset of symptoms and (b) treatment after acteristics such as age, marital status, religion, education, 24 hr (delay). place of residence, and so on, were examined. The bivariate analysis involved comparison and testing for significance Result of the Study between two variables such as mothers place of residence and type of treatment sought, mothers’ education and type of The Table 1 below presents the sociodemographic characteris- treatment sought, and so on. The third stage involved the tics of the respondents. Majority of the mothers are within the multivariate analysis that further analyzed the relationships age 25 and 39 (64.1%) while 95.1% of them are married with between independent and dependent variables. At this stage, shared religious affiliation as Christian (43.1%) and Muslim logistic regression models were used based on the selected (54.9%). Almost half (46.5%) of the women had no education, variables that were significant at the bivariate level. while 31.0% and 22.5% had primary and post secondary edu- Therefore, the following regression models were devel- cation, respectively. By occupation, more than half (67.3%) of oped to predict the likelihood of medical and prompt treat- the mothers were working at the time of the survey. About half ment of malaria. (49.2%) of the respondents are within the lower wealth index. Also, three quarter (75.1%) of the respondents lives in the Model 1. (Model built with socioeconomic factors and type of rural area as one quarter of their counterparts lives within the treatment sought) urban centers (24.9%). By region of residence, 22.0%, 30.0%, 14.0%, and 17.2% of the women lives in North-East, North-  P  log = ab + Xb + Xb + Xb ++  X , West, South-East, and South-South, respectively, while others   11 22 33 nn 1-P   lives in North-Central (8.3%) and South-West (8.5%), respec- where P is probability of accessing medical treatment for tively. More than half (54.1%) of the children received medi- malaria, a is the intercept, b s are the slopes, X is respon- cal treatment; about one third (27.6%) received traditional or i 1 dents’ religion, X is respondents’ level of education, X is home-based treatment whereas about one fifth received no 2 3 respondents’ occupational status, X is respondents’ place of treatment during the recent episode of malaria. In addition, residence, X is respondents’ wealth quintile, and X is more than half (52.7%) of the mothers delayed in seeking 5 6 respondents’ barrier to access health care facilities (n = 6). medical treatment for their children while less than half (47.3%) of their counterparts sought prompt medical treat- Model 2. (Model built with selected significant socioeconomic ment for their children. In assessing barrier to access health factors and delay in accessing health care) care, findings showed that about one third (31.9%) of mothers had no barrier, one fifth (21.0%) had permission as a con-  P  log = a + bX + bX + bX + +b X , straint, and more than one tenth (14.5%) had permission and   11 22 33 nn 1-P   money as a barrier, while 23.3% and 9.3% of the rest had per- where P is the probability of accessing prompt treatment, a is mission/money/distance/transportation as a barrier in access- the intercept, b s are the slopes, X is respondents’ wealth ing health care facilities. 1 1 index, X is respondents’ place of residence (n = 2). The Table 2 below presents the bivariate analysis of the All the analysis was done at 95.0% significance level (p relationship between mothers’ socioeconomic characteris- -value, < 0.05). tics, type of treatment sought, and delay in seeking treatment. From the table, findings revealed no significant relationship between marital status (χ = 11.32, p > .05) and type of treat- Measurement of Some Variables ment sought. Across all ages (χ = 16.40, p < .05), tendency •• Malaria: Fever was used as a proxy for malaria. to seek medical treatments increases consistently with age of According to the NDHS, fever is the main symptom mothers. The proportion of never married (65.1%), wid- of malaria, the proportion of febrile children in the owed, or divorced women (66.3%) who sought medical population is a proxy for assessing malaria preva- treatment for their children is 10% point greater than the pro- lence, and any reduction in the malaria disease burden portion of their married women (53.6%) counterparts. should lead to a reduction in the overall prevalence of Findings on mothers’ age (χ = 1.96, p > .05) and marital fever (NPC & ICF Macro, 2009) status (χ = 3.70, p > .05) show no significant relationship •• Type of treatment: Type of treatment was accessed in with delay in seeking treatment. Overall, 47.3% of mothers three ways: (a) no treatment, (b) home/traditional received prompt treatment for their children against their treatment, and (c) medical treatment at second level of counterparts (52.7%) who delayed in seeking treatment for analysis (Note: level of treatment was dichotomized their children. By marital status, less than half of never mar- at the third level of analysis into: 1. Medical treat- ried mothers (41.4%) and married mothers (47.3%) treat ment, 0. Otherwise). their children promptly within 24 hr of onset of symptoms as •• Delays in seeking treatment: Delay in treatment was against more than half (57.2%) of widowed/divorced moth- categorized into two: (a) treatment within 24 hr ers who treat their children promptly. 4 SAGE Open Table 1. Percentage Distribution of Respondents by Also, there exists a significant relationship between reli- 2 2 Sociodemographic Characteristics. gion (χ = 216.24, p < .05), education (χ = 257.55, p < .05), 2 2 occupation status (χ = 21.88, p < .05), wealth index (χ = Variables Frequency % 207.08, p < .05), type of residence (χ = 18.56, p < .05), Age region of residence (χ = 350.82, p < .05), and type of treat- 15-24 1,015 25.6 ment sought for malaria. The proportion of Christian moth- 25-34 1,935 64.1 ers who sought medical treatment (66.2%) for their children 35-40+ 1,018 10.3 is about 20% point greater than the proportion of their Current marital status Muslim (44.6%) counterparts who sought medical treatment Never married 120 3.0 for their children. Meanwhile, of those who sought medical Married 3,771 95.1 treatment, less than half (48.4%) of Christian mothers and Widow/divorced 77 1.9 46.2% of Muslim mothers sought prompt medical treatment Religion as against more than half (51.8% vs. 53.5%) of their counter- Christian 1,713 43.1 parts who delayed in seeking treatment. Islam 2,177 54.9 Type of treatment and delay in seeking treatment varies Others 78 2.0 consistently with mothers’ level of education: 69.0% for Level of education mothers with secondary education and above, 59.0% for No education 1,846 46.5 those with primary education, and 49.0% for those with no Primary 893 22.5 education. The percentage of mothers who did not seek any Secondary+ 1,229 31.0 treatment or sought treatment at home/traditional places is Occupational status 10% point lower among mothers with primary (12.6% and Not working 1,299 32.7 27.9%) education compared with their counterparts without Currently working 2,669 67.3 any education (25.8% and 32.5%). Although not significant, Wealth index Lower 1,954 49.2 but the proportion of mothers who gave prompt malaria Middle 765 19.3 treatment to their children increased consistently with level Upper 1,249 31.5 of education: 44.8% versus 55.2% of mothers with no educa- Place of residence tion; 47.3% versus 52.7% of those with primary education; Urban 987 24.9 and 50.4% versus 49.6% of those with secondary or post sec- Rural 2,981 75.1 ondary education sought prompt malaria treatment and Region delayed treatment, respectively, for their children. North-Central 330 8.3 By occupational status, 56.7% of working mothers against North-East 872 22.0 48.8% of non-working mothers received medical treatment North-West 1,189 30.0 for their children while 17.3% and 26.0% of working moth- South-East 555 14.0 ers as against 20.3% and 31.0% of non-working mothers South-South 682 17.2 received no treatment and home/traditional treatment for South-West 340 8.5 their children. Meanwhile, the proportion of mothers with Type of treatment prompt malaria treatment increase slightly with occupational No treatment 723 18.2 status: 47.8% for working mothers versus 46.0% for non- Medical treatment 2,148 54.1 working mothers. Traditional/others 1,097 27.6 Also, more than half, 59.5% and 68.2%, of mothers within Delay in seeking treatment the middle and higher wealth index against 43.0% of those No delay (within 1,306 47.3 within the lower wealth index sought medical treatment for 24 hr) their children. Of those who sought treatment, larger percent- Had delay (>24 hr) 1,457 52.7 age of mothers (57.9%) in the lower wealth index delayed as Barrier to access health care No problem 1,265 31.9 against 45.0% and 50.1% of their counterparts within the Permission 836 21.0 middle and higher wealth index that delayed in seeking treat- Permission/money 575 14.48 ment for malaria. Meanwhile, 58.7% versus 52.6% of urban Permission/money/ 925 23.3 and rural women sought medical treatment, respectively, distance while the percentage of rural women who delayed in seeking Permission/money/ 367 9.3 treatment is about 10% point greater than the percentage of distance/transport their urban counterparts that delayed in seeking medical Total 3,968 100.0 treatment. By region of residence, more than half of the mothers in Source. Author’s work; Data computed from 2008 Nigeria Demographic and Health Survey. the South-East (71.9%), South-South (66.3%), North-Central Kolawole and Asaolu 5 Table 2. Sociodemographic Factors Associated with Type of Treatment Sought and Delays in Seeking Treatment for Childhood Malaria. Delay in treatment (after Type of treatment (%) detecting symptom) No Traditional/ No delay (24 Has delay (2 2 2 Region treatment home Medical Total χ hr) days+) Total χ Age <24 197 (19.4) 304 (30.0) 514 (50.6) 1,015 16.396** 318 (46.3) 369 (53.7) 687 1.968 25-34 330 (17.1) 494 (25.5) 1,111 (57.4) 1,935 646 (46.6) 740 (53.4) 1,387 35-40+ 196 (19.2) 298 (29.3) 524 (51.5) 1,018 341 (49.6) 347 (50.5) 688 Total 723 (18.2) 1,097 (27.6) 2,148 (54.1) 3,968 1,306 (47.3) 1,457 (52.7) 2,762 Marital status Never married 15 (12.2) 27 (22.7) 78 (65.1) 220 11.324 37 (41.4) 52 (58.6) 88 3.700 Married 699 (18.5) 1,053 (27.9) 2,020 (53.6) 3,772 1,235 (47.2) 1,380 (52.8) 2,614 Widow/divorced 9 (12.1) 17 (21.6) 51 (66.3) 77 34 (57.4) 26 (42.6) 60 Total 723 (18.2) 1,097 (27.6) 2,148 (54.1) 3,968 1,306 (47.3) 1,457 (52.7) 2,762 Religion Christian 168 (9.8) 411 (24.0) 1,134 (66.2) 1,713 216.239** 601 (48.2) 646 (51.8) 1,246 0.803 Islam 540 (24.8) 666 (30.6) 971 (44.6) 2,177 680 (46.5) 781 (53.5) 1,461 Others 14 (18.1) 20 (25.6) 44 (54.1) 77 25 (45.8) 30 (54.2) 55 Total 723 (18.2) 1,097 (27.6) 2,148 (54.1) 3,968 1,306 (47.3) 1,457 (52.7) 2,762 Level of education No education 476 (25.8) 601 (32.5) 770 (41.7) 18.46 257.552** 540 (44.8) 665 (55.2) 1,205 6.701 Primary 113 (12.6) 249 (27.9) 531 (59.5) 893 294 (47.3) 328 (52.7) 622 Secondary+ 135 (11.0) 247 (20.1) 847 (69.0) 1,229 472 (50.4) 464 (49.6) 935 Occupational status Not working 262 (20.2) 403 (31.0) 635 (48.8) 1,299 21.885** 395 (46.0) 464 (54.0) 858 0.818 Currently working 461 (17.3) 694 (26.0) 1,514 (56.7) 2,669 911 (47.8) 993 (52.2) 1,904 Wealth index Lower 459 (23.5) 654 (33.5) 841 (43.0) 1,954 207.084** 531 (42.1) 731 (57.9) 1,262 29.111** Middle 117 (15.3) 193 (25.3) 455 (59.5) 765 300 (55.0) 246 (45.0) 546 Upper 148 (11.8) 250 (20.0) 852 (68.2) 1,249 475 (49.7) 480 (50.3) 955 Residence Urban 186 (18.9) 221 (22.4) 580 (58.7) 987 18.555** 383 (52.5) 347 (47.5) 730 10.876** Rural 537 (18.0) 876 (29.4 1,568 (52.6) 2,981 923 (45.4) 1,109 (54.6) 2,032 Region North-Central 41 (12.3) 91 (27.5) 199 (60.2) 331 350.824** 85 (37.1) 144 (62.9) 229 98.818** North-East 289 (33.1) 212 (24.2) 372 (42.6) 872 332 (52.2) 304 (47.8) 636 North-West 259 (21.8) 408 (34.3) 522 (43.9) 1,189 336 (44.1) 427 (55.9) 763 South-East 58 (10.5) 98 (17.6) 399 (71.9) 555 278 (65.3) 148 (34.7) 426 South-South 52 (7.6) 178 (26.1) 452 (66.3) 682 201 (40.5) 294 (59.5) 495 South-West 24 (7.1) 112 (32.8) 204 (60.1) 340 74 (34.5) 140 (65.5) 214 Total 723 (18.2) 1,097 (27.6) 2,148 (54.1) 3,968 1,306 (47.3) 1,457 (52.7) 2,762 Barriers to access HCF No barriers 225 (17.8) 297 (23.5) 743 (58.7) 1,265 79.827** 430 (46.4) 497 (53.6) 927 3.363 Permission 110 (19.2) 133 (23.1) 332 (57.7) 575 276 (47.3) 308 (52.8) 583 Permission/money 142 (17.0) 233 (27.9) 461 (55.1) 836 190 (44.6) 236 (55.4) 426 Permission/money/ 166 (17.9) 277 (30.0) 482 (52.1) 925 313 (49.4) 321 (50.6) 634 distance Permission/money/ 80 (21.9) 157 (42.8) 130 (35.3) 367 97 (50.3) 95 (49.7) 192 distance/transport Total 723 (18.2) 1,097 (27.6) 2,148 (54.1) 3,968 1,306 (47.3) 1,457 (53.7) 2,762 Note. HCF = health care facilities. **p, .05 (at 95% significance). (60.2%), and South-West (60.1%) sought medical treatment treatment for their children. Meanwhile, North-East (21.7%) for their children, while about one third of them in the North- and North-West (33.1), across all regions, signify a region East (24.2%), North-West (34.3%), North-Central (27.5%), with higher percentage of children without any treatment and South-West (32.8%) received either home or traditional during the illness. 6 SAGE Open As the numbers of difficulties faced in seeking treatment Finally, the likelihood of seeking medical treatment increase (57.7% for permission; 55.1% for permission and among mothers with four different barriers or difficulties money; 52.1% for permission, money, and distance; and combined (permission, money, distance, transport) is consis- 35.3% for permission, money, distance, and transportation), tently and significantly less (OR = 0.53; p < .05; CI = [0.38 the percentage of women who sought medical treatment for - 0.75]) when compared with their counterparts with either their children decreases, respectively. Also, the proportion of barriers/difficulties with permission (OR = 1.12; p > .05; CI mothers whose children received prompt treatment varies = [0.88 - 1.45]); barriers/difficulties with permission and consistently with numbers of difficulties encountered. money (OR = 0.84; p > .05; CI = [0.69 - 1.14]); or barriers/ The Table 3 below presents the odds ratio (OR) of the difficulties with permission, money, and distance (OR = general binary logistic regression for the likelihood of receiv- 0.86; p > .05; CI = [0.69 - 1.08]); as well as those without any ing medical and prompt treatment for children aged 12 to 59 barrier/difficulties. months who had malaria within 2 weeks preceding the sur- vey. The logistic regression was built with two models by Discussion of Findings selecting all mothers’ socioeconomic factors that have a sig- nificant relationship with type of treatment and delay in This study examined mothers’ socioeconomic differentials treatment at the bivariate level of analysis. The first model and management of childhood malaria using the 2008 NDHS therefore examined the likelihood of receiving medical treat- kids recode data set. Overall, 3,968 children had fever 2 ment with the selected mothers’ socioeconomic factors while weeks before the survey with majority of them within the age the second model examined the odds of giving prompt treat- bracket 12 to 35 months. Averagely across all ages, exactly ment with the selected significant socioeconomic factors at half of the children received treatment from medical centers, the bivariate level of analysis having controlled for region of about one third received treatment at home or traditional residence. health providers while about one fourth of the rest received Findings from logistic regression at this multivariate level no treatment at all. Meanwhile, against the fourth key ele- of analysis showed that the odds of seeking medical treat- ment of RBM strategy of accessing appropriate and adequate ment for children by their mothers vary proportionally with treatment within 24 hr of onset of symptoms, a little more level of education. Mothers with no education (OR = 0.62; than half of the mothers delayed beyond 24 hr before seeking p < .05; CI = [0.47- 0.81]) and primary education (OR = treatment for their children. In line with D’Souza’s (2003) 0.67; p > .05; CI = [0.67- 1.14]) are less likely to seek medi- research findings, delay in seeking treatment could be influ- cal treatment for their children compared with their counter- enced by past experience with similar illnesses which moti- parts with secondary education and above. Mothers within vate mothers to play a “waiting game” to see if the illness the middle (OR = 0.77; p < .05; CI = [0.59 - 1.00]) and lower subsides on its own, particularly in situations where the cost wealth index (OR = 0.49; p < .05; CI = [0.37 - 0.64]) are of care is an inhibitory factor (D’Souza, 2003). significantly less likely to seek medical treatment; as they are Urban mothers were found to have better chance of giving also less likely to seek prompt treatment (OR = 0.91; p > .05; their children medical and prompt treatment during malaria CI = [0.98 - 1.76] vs. OR = 0.81; p > .05; CI = [0.62 - 1.05]) illness than their rural mother counterparts. Also, greater per- for their children when compared with mothers within the centage of children within South-East, South-South, North- higher wealth index. Central, and South-West regions received medical treatment Meanwhile, the logistic regression at this level found no when compared with other regions. Conversely, greater per- significant relationship between mothers’ occupational status centage of mothers in the North-East, North-West, and and likelihood of seeking medical and prompt treatment for North-Central have the highest proportion of children with childhood malaria. However, findings showed that the odds fever whose treatment were delayed or were not treated at al of seeking medical treatment among mothers who were not or treated at home with traditional herbal medicine. These working (OR = 0.88; p > .05; CI = [0.57 - 0.88]) is less when findings are in line with Guyatt and Snow’s (2004), Kofoed compared with that of their counterparts in the working class et al.’s (2004), and Müller et al.’s (2003) research findings, category. Furthermore, Islamic mothers (OR = 0.72; p < .05; which concluded that malaria treatments are rarely sought at CI = [0.55 - 1.71]) and those in the other religion (OR = 0.98; health care facilities and are most often inappropriate or p < .05; CI = [0.14 - 2.27]) are significantly less likely to take delayed. their children for medical treatment compared with their The significant relationship found between religion, med- Christian counterparts. ical choice of treating malaria, and prompt treatment of Also, the odds of giving medical treatment (OR = 0.34; malaria corroborate earlier findings by Adamu (2001), Addai p > .05; CI = [1.07 - 1.69]) as well as prompt treatment (OR (2000), and Adetunji (1996), as this study revealed that = 0.82; p > .05; CI = [0.63 - 1.06]) among mothers in the Islamic mothers and those in the other religion are signifi- rural area are significantly less when compared with the odds cantly less likely to give medical and prompt treatment to of giving medical treatment as well as prompt treatment their children during malaria illness when compared with among mothers in the urban centers. their Christian counterparts. Kolawole and Asaolu 7 Table 3. General Binary Logistic Regression Models 1 and 2 for the Likelihood of Receiving Medical and Prompt Treatment for Children Aged 12 to 59 Months who had Malaria within 2 Weeks Preceding the Survey. Type of treatment received (medical treatment) Delay in accessing medical treatment (no delay) Model 1 Model 2 Selected variables Odds ratio (SE) p value 95% CI Odds ratio (SE) p value 95% CI Socioeconomic factors Level of education Secondary+ RC None 0.62 (0.09) .001** [0.47 - 0.81] Primary 0.88 (0.12) .334 [0.67 - 1.14] Wealth index Higher class RC RC Middle class 0.77 (0.10) .049** [0.59 - 1.00] 0.91 (0.20) .065 [0.98 - 1.76] Lower class 0.49 (0.07) .000** [0.37 - 0.64] 0.81 (0.11) .107 [0.62 - 1.05] Occupation status Working RC Not working 0.88 (0.08) .158 [0.74 - 1.05] Religion Christianity RC Islam 0.72 (0.08) .004** [0.57 - 0.88] Others 0.98 (0.28) .940 [0.55 - 1.71] Place of residence Urban RC RC Rural 0.34 (0.16) .011** [1.07 - 1.69] 0.82 (0.11) .131 [0.63 - 1.06] Barriers to in access HCF No constraint RC Permission 1.12 (0.15) .346 [0.88 - 1.45] Per/money/ 0.86 (0.09) .186 [0.69,- - 1.08] Per/money/distance 0.84 (0.11) .355 [0.69 - 1.14] Per/money/distance/ 0.53 (0.09) .000** [0.38 - 0.75] transport Note. Standard errors are in parenthesis. Model 1 = Model built with significant socioeconomic factors and type of treatment; Model 2 = Model built with selected significant socioeconomic factors and delays in accessing health care. CI = confidence interval; RC = reference category; HCF = health care facilities. **p, .05. In line with earlier studies by Pérez-Cuevas et al. (1996) malaria for their children. In addition, mothers’ wealth index and WHO/UNICEF (2003), which associate maternal literacy showed a significant relationship with type of treatment and mothers’ education with utilization of health care facili- sought and delay in seeking treatment. Mothers within the ties, this study also revealed that type of treatment and prompt middle and lower wealth index are significantly less likely to treatment of malaria varies monotonically with mothers’ level seek medical treatment; as they are also less likely to seek of education. Mothers with no education or with primary edu- prompt treatment for their children when compared with cation are less likely to seek medical and prompt treatment for their counterparts within the higher wealth index. their children compared with their counterparts with second- Furthermore, findings revealed that larger percentages of ary education or more. Efforts therefore need to be intensified urban mothers sought medical treatment for their children on health education with emphasis on the importance of iden- when compared with their counterparts in the rural areas. tifying vital malaria signs and giving prompt and appropriate The odds of giving medical treatment and prompt treatment care to febrile children within 24 hr of onset of the symptoms among mothers in the rural area was found to be significantly as advocated by WHO (2004). less when compared with the odds of giving medical treat- Also, this study showed that the proportion of mothers ment and prompt treatment among mothers in the urban cen- with prompt malaria treatment increased slightly with occu- ters. In addition, our findings showed that rural mothers are pational status. That is, mothers who are currently working more likely to delay in seeking treatment compared with are more likely to seek medical and prompt treatment of their urban counterparts. These findings are in line with the 8 SAGE Open studies conducted by Adeyemi (2000), Mekonnen and associated with medical and prompt treatment of malaria, Mekonnen (2002), Sabitu (2004), and UNFPA (2002, 2004), investing in women’s education through free education as which concluded that there are differences in utilization of well as intensive campaign to motivate them to go for higher health care facilities and maternal health care services level of education will be a worthwhile effort. Higher educa- between urban and rural areas. tion will enhance their wealth index and occupational status Findings on barrier or difficulties in accessing health care which will in turn have a positive influence on their ability to facilities and prompt treatment revealed a significant relation- care for children. ship in line with research findings by Hill et al. (2003), Mermert and Nsabagasanyi (2002), and Namusobya (1998), where they Limitation of the Study concluded that lack of finance for medical consultation and treatment, distance from health care facilities, and so on, are The study make use of a secondary data obtained from the important barriers to accessing health care facilities. Therefore, 2008 Nigeria Demographic and Health Survey, which is a these research findings also concluded that difficulties/barriers nationally representative data, and the author was not oppor- to access health care facilities significantly decrease medical tune to get the data in its natural settings. Thus, there are and prompt treatment of malaria in children. some limitations as predetermined by the data in terms of the questionnaire design and variable measured. For instance, mothers’ knowledge of severity of malaria sickness as well Conclusion and Policy as perceived benefit of prompt initiation of treatment was not Recommendation measure and therefore cannot be measured by this study. Having used both bivariate and multivariate level of analysis, Also, cases of missing values and high non-response rate are findings from this study concluded that mothers’ socioeco- common in the data set, and this was responsible for some nomic characteristics and barriers to access health care facili- variation in the row totals in the “Analysis” section. ties are significant factors militating against medical and prompt treatment of malaria in Nigeria. As revealed by this Declaration of Conflicting Interests study, about 50% of febrile children are never seen within The author(s) declared no potential conflicts of interest with respect health care facilities. They are either treated at home or not to the research, authorship, and/or publication of this article. treated at all. Therefore, appropriate and prompt use of health care facilities for treatment of malaria within 24 hr of onset of Funding symptoms are critical to the successful achievement of the The author(s) received no financial support for the research and/or United Nation’s Millennium Development Goal 4, which authorship of this article. calls for a two thirds reduction in child mortality by 2015. Although, National Policy on Malaria Diagnosis and References Treatment (Federal Ministry of Health, 2005, 2010) pro- motes the treatment of uncomplicated malaria at home with Adamu, Y. M. (2001, July). Spatio-temporal analysis of maternal mortality in Kano State. Paper presented to the Department of artemisinin-based combination therapies (ACTs). However, Geography, Bayero University Kano, Nigeria. it is disappointing that many people did not know about Addai, I. M. (2000). 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Interactions between patent medicine no accessible roads to the health centers, which in turn are vendors and customers in urban and rural Nigeria Annals of poorly equipped and have inadequate drugs for malaria treat- Ibadan Postgraduate Medicine. Retrieved from http://www. ment. This poses a serious threat to clinical management and ncbi.nlm.nih.gov/pubmed/15070866. treatment of malaria and also influence people who cannot D’Souza, R. M. (2003). Role of health-seeking behaviour in afford anti-malarial drugs to tend toward self-medication child mortality in the slums of Karachi, Pakistan. Journal of with local herbs. Finally, as mothers’ education has been Biosocial Science, 35, 131-144. Kolawole and Asaolu 9 Ene-Obong, H. N., Uwaegbute, A. C., Iroegbu, C., & Amazigo, febrile illness in a rural community in Nigeria. Australian A. U. (1998). The effect of two child-care practices of mar- Journal of Rural Health, 13, 97101. ket women on diarrhoea prevalence, feeding patterns and Pate, U. A. (2001). A United Nation Population Fund (UNFPA) nutritional status of children aged 0-24 months. Journal of formative research on reproductive health in Borno State. A Diarrhoeal Diseases Research, 16, 173-179. report submitted to United Nation Population Fund (UNFPA) Fapohunda, B. M., & Beth, A. P. (2004). The home based man- Office, Nairobi, Kenya. agement of fever strategy in Uganda: Survey report 2004. Pérez-Cuevas, R., Guiscafré, H., Romero, G., Rodríguez, L., & Kampala, Uganda: BASICS II/FMoH/WHO/USAID. Gutiérrez, G. (1996). Mothers’ health-seeking behaviour in Federal Ministry of Health. (2005). National antimalarial treatment acute diarrhoea in Tlaxacala, Mexico. Journal of Diarrhoeal policy. Abuja, Nigeria: Federal Ministry of Health, National Diseases Research, 14, 260-268. Malaria and Vector Control Division. Sabitu, K. 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Nigerian Reproductive agement of childhood diseases in Yorubaland: The influence of Health Resources and Services Survey. Abuja, Nigeria: cultural beliefs. Health Transition Review, 7, 221-234. Somaprint. Guyatt, H. L., & Snow, R. W. (2004). The management of fevers United Nations Population Fund. (2004). Reproductive health and in Kenyan children and adults in an area of seasonal malaria gender indicators (Report on 2004 Baseline Survey of UNFPA transmission. Transactions of the Royal Society of Tropical Assisted States in Nigeria, UNFPA Programme of Assistanceto Medicine & Hygiene, 98, 111-115. Nigeria 2003-2007). Abuja, Nigeria: Somaprint. Hill, Z., Kendall, C., Arthur, P., Kirkwood, B., & Adjei, E. (2003). USAID/PMI. (2011). Economic section, United States Embassy in Recognizing childhood illnesses and their traditional explana- Nigeria. Abuja, Nigeria. Available from http://nigeria.usem- tions: Exploring options for care-seeking interventions in the bassy.gov context of the IMCI strategy in rural Ghana. Tropical Medicine World Health Organization. (1999). Rolling back malaria: World & International Health, 8, 668-676. health report 1999. Retrieved from www.who.int/whr/1999/ Jimmy, E. O., Achelonu, E., & Orji, S. (2000). Antimalarials dis- en/whr99_ch4_en.pdf pensing pattern by patent medicine dealers in rural settlements World Health Organization. (2004). Scaling-up home-based man- in Nigeria. Public Health, 114, 282-285. agement of malaria: From research to implementation (WHO/ Jones, G., Steketee, R. W., Black, R. E., Bhutta, Z. A., Morris, S. HTM/MAL/2004.1096). Geneva, Switzerland: Author. S., & Bellagio Child Survival Study Group. (2003). How many World Health Organization. (2006). Guidelines for the treatment of child deaths can we prevent this year? The Lancet, 362, 65-71. malaria (WHO/HTM/MAC/2006.1108). Geneva, Switzerland: Kofoed, P. E., Rodrigues, A., Hedegaard, K., Rombo, L., & Aaby, Author. P. (2004). Which children come to the health centre for treat- World Health Organization. (2008, August 28-September 1). Child ment of malaria? Acta Tropica, 90, 17-32. survival: A strategy for the African Region (AFR/RC56/13). Mekonnen, Y., & Mekonnen, A. (2002). Utilization of maternal Brazzaville, Congo: Author. health care services in Ethiopia. Calverton, MD: ORC Marco. World Health Organization. (2010). Guidelines for the treatment of Mermert, L., & Nsabagasanyi, X. (2002). Buying and selling of malaria (2nd ed.). Geneva, Switzerland: Author. malaria treatment in the private drug outlets in Uganda. CMS- World Health Organization/United Nations Children’s Emergency Uganda. MoH (2001). pdf.usaid.gov/pdf_docs/Pnadu090.pdf Fund. (1997). Integrated management of childhood illnesses: Müller, O., Traore, C., Becher, H., & Kouyate, B. (2003). Malaria A WHO/UNICEF initiative. Bulletin of the World Health morbidity, treatment-seeking behaviour, and mortality in Organization, 75, 25-32. a cohort of young children in rural Burkina Faso. Tropical World Health Organization/United Nations Children’s Emergency Medicine & International Health, 8, 290-296. Fund. (2003). Africa malaria report (WHO/CDS/MAL/2003. Namusobya, J. I. (1998). Factors associated with high morbid- 1093). Geneva, Switzerland: World Health Organization. ity and mortality due to malaria in Iganga district—Uganda Retrieved from http://mosquito.who.int/amd2003/amr2003 (Unpublished).District Medical Office, Iganga, Uganda. National Population Commission (NPC) [Nigeria] & ICF Macro. Author Biographies (2009). Nigeria Demographic and Health Survey 2008. Abuja, Ojewumi Titus Kolawole is a demographer and a PhD research Nigeria: Author. fellow in the Department of Demography and Social Statistics, Okonkwo, P. O., Akpala, C. O., Okafor, H. U., Mbah, A. U., & Faculty of Social Sciences, Obafemi Awolowo University, Ile-Ife. Nwaiwu, O. (2001). Compliance to correct dose of chloroquine in uncomplicated malaria correlates with improvement in the Asaolu Olugbenga Stephen is a public health specialist currently condition of rural Nigerian children. Transactions of the Royal working with the Association for Reproductive and Family Health, Society of Tropical Medicine & Hygiene, 95, 320-324. as the senior monitoring and evaluation officer on the U.S. Agency Olaogun, A. A., Ayandiran, O., Olasode, O. A., Adebayo, A., & for International Development (USAID)-funded 5-year LOPIN- Omokhodion, F. (2005). Home management of childhood Region 1 project in Nigeria. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png SAGE Open SAGE

Mothers’ Socioeconomic Differentials and Management of Malaria in Nigeria:

SAGE Open , Volume 6 (2): 1 – May 20, 2016

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Abstract

About 150 million Nigerians live in areas of intense malaria transmission. Malaria has the greatest prevalence, close to 50% in children aged 6 to 59 months. A review of literatures revealed that more than 80% of malaria episodes received treatment outside of the existing government health care system. This means that treatments are rarely sought at health care facilities and are most often inappropriate or delayed. Reasons underlying these practices range from mothers’ socioeconomic status to difficulty in accessing health care facilities. Therefore, this study re-examined whether mothers’ socioeconomic characteristics and barriers to access health care facilities are major factors that influence mothers’ choice of treatment and delays in seeking treatment of malaria among under-five children in Nigeria. The study used Nigeria Demographic and Health Survey kids recode dataset. The data were analyzed using STATA 12 software. The result showed significant relationship 2 2 2 between religion (χ = 216.24, p < .05), education (χ = 257.55, p < .05), occupation status (χ = 21.88, p < .05), wealth index 2 2 2 (χ = 207.08, p < .05), type of residence (χ = 18.56, p < .05), region of residence (χ = 350.82, p < .05), and type of treatment sought and delay in seeking treatment for malaria. Also, the likelihood of seeking medical and prompt treatment among mothers with four different barriers is significantly less (odds ratio = 0.53; p < .05; 95% confidence interval = [0.38- 0.75]), when compared with their counterparts without any barrier. The study concluded that mothers` socioeconomic status and access to health care facilities must be improved to ensure appropriate and prompt use of health care facilities for treatment of malaria among under-five children in Nigeria. Keywords social sciences, under-five, mortality, demographics, early childhood, education, socioeconomic, childhood, malaria, Nigeria South-West, North-Central, and North-West regions while it Introduction has the least prevalence, 27.6%, in children aged 6 to 59 Malaria poses a major public health challenge as the third months in the South-East region (USAID/PMI, 2011). leading cause of death among under-five children world- According to studies, an estimated one in five child deaths is wide. About 3.3 billion people are affected by malaria, due to malaria, which accounts for more than 300,000 deaths almost half of the world’s population, in 106 countries and among under-five children every year. It is also believed to territories. World Health Organization (WHO) estimates that contribute up to 11% maternal mortality, 25% infant mortal- 216 million cases of malaria occurred in 2010, 81% in the ity, and 30% under-five mortality in Nigeria. In addition to African region that resulted in 655,000 malaria deaths in the direct health impact of malaria, there are also severe 2010, and 86% were children under 5 years of age (WHO, social and economic burdens on communities and the coun- 2010). Thirty countries in sub-Saharan Africa account for try as a whole, with about 132 billion Naira lost to malaria 90% of global malaria deaths. Nigeria, Democratic Republic annually in the form of treatment costs, prevention, loss of of Congo (DRC), Ethiopia, and Uganda account for nearly work time, and so on (Federal Ministry of Health, 2009). 50% of the global malaria deaths. Malaria is the second lead- As part of the child survival strategy, WHO and United ing cause of death from infectious diseases in Africa, after Nations Children’s Emergency Fund (UNICEF), in 1995, HIV/AIDS, and the third leading cause of death for children after pneumonia and diarrheal disease worldwide (U.S. Agency for International Development [USAID]/ President’s 1 Obafemi Awolowo University, Ile-Ife, Nigeria Malaria Initiative [PMI], 2011). Association for Reproductive and Family Health, Ibadan, Nigeria About 150 million Nigerians—almost the entire popula- Corresponding Author: tion of the country—live in areas of intense malaria trans- Ojewumi Titus Kolawole, Obafemi Awolowo University, Ile-Ife, Osun, mission (WHO, 2008). Malaria has the greatest prevalence, Nigeria. close to 50%, in children aged 6 to 59 months in the Email: ojetitus1@gmail.com Creative Commons CC-BY: This article is distributed under the terms of the Creative Commons Attribution 3.0 License (http://www.creativecommons.org/licenses/by/3.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 SAGE Open intensified effort and initiated the Integrated Management of care could reduce child deaths due to malaria, diarrhea, and Childhood Illnesses (IMCI) to assist developing countries acute respiratory infections by 20% (WHO, 1999). However, reduce childhood mortality caused by most childhood killer there are controversial findings on whether the use of mod- diseases: diarrhea, acute respiratory infections, malaria, ern health services is often influenced by individual percep- measles, and malnutrition.(WHO/UNICEF, 1997). Malaria tions of the efficacy of modern health services, religious control activities in Nigeria are planned and implemented beliefs, residence, occupation, place of delivery, wealth sta- through the primary health care (PHC) system (WHO, 2006). tus, level of education, and so on (Adetunji, 1996; Adeyemi, The strategy used for the implementation of the national anti- 2000; Ene-Obong, Uwaegbute, Iroegbu, & Amazigo, 1998; malarial treatment policy is that of Roll Back Malaria (RBM). Fapohunda & Beth, 2004; Hill, Kendall, Arthur, Kirkwood, The RBM strategy for the control of malaria has as one of its & Adjei, 2003; Mekonnen & Mekonnen, 2002; Pate, 2001; key elements that patients with malaria should have access to Sabitu, 2004; United Nations Population Fund [UNFPA], appropriate and adequate treatment within 24 hr of the onset 2002, 2004). Therefore, this article examined the influence of symptoms. However, the use of health care facilities as the of mothers’ socioeconomic characteristics and barriers to first resort for malaria and treatment/management has been access health care facilities on mothers’ choice of treatment shown to be low in many African countries, including and delays in seeking treatment of malaria among under-five Nigeria. Treatments are rarely sought at health care facilities children in Nigeria. and are most often inappropriate or delayed (Guyatt & Snow, 2004; Kofoed, Rodrigues, Hedegaard, Rombo, & Aaby, Research Questions 2004; Müller, Traore, Becher, & Kouyate, 2003). Less than 15% of the malaria episodes treated at home is treated cor- Against the above background, the fundamental questions rectly. Most fevers in children are treated with simple fever that readily come to mind are as follows: drugs, such as paracetamol and aspirin, but not with anti- malarial drugs. Even when anti-malarial drugs are purchased, Research Question 1: Do mothers’ socioeconomic char- they are commonly administered in inappropriate doses acteristics (age, level of education, occupation, religion, (WHO, 2004). wealth index, etc.) have significant influence on type of A review of mothers’ malaria treatment-seeking behavior treatment sought and prompt treatment of febrile illness? in Nigeria revealed that more than 80% of malaria episodes Research Question 2: Does barrier in accessing health received treatment outside the existing government health care facilities have any influence on type of treatment and care system (Ajayi & Falade, 2006; Olaogun, Ayandiran, prompt treatment of malaria? Olasode, Adebayo, & Omokhodion, 2005). Reasons under- lying these practices range from maternal literacy and health Method education, socioeconomic status, difficulty in accessing health care facilities, attitude of health personnel, cultural Data Collection Method beliefs on the ease of use of traditional herbs, and support for The Nigeria Demographic and Health Survey (NDHS) kids treatment offered by other household members (Feyisetan, recode data set was used for this study. The survey was cross- Asa, & Ebigbola, 1997; Mermert & Nsabagasanyi, 2002; sectional. It was designed to provide specific information on Namusobya, 1998; Pérez-Cuevas, Guiscafré, Romero, population and health indicators at the national, zonal, and Rodríguez, & Gutiérrez, 1996; WHO/UNICEF, 2003). state levels. Information collected includes birth histories, These shortcomings encourage treatment of malaria at in-depth demographic and socioeconomic information on ill- home with drugs bought from shops and herbal preparations nesses, medical care, immunizations, and anthropometric (Baume, Helitzer, & Kachur, 2000; Pérez-Cuevas et al., details of children (National Population Commission [NPC] 1996; Salako et al., 2001). “These treatments are usually [Nigeria] & ICF Macro, 2009). Therefore, from the sampling incorrect or sub-optimal” (Brieger, Osamor, Salami, Oladepo, frame of 33,385 of all married women interviewed in Nigeria, & Otusanya, 2004; Jimmy, Achelonu, & Orji, 2000). Mothers 18,028 women with at least a child aged 12 to 59 years were and caregivers only usually visit a health centre or hospital extracted, out of which 3,068 women whose child has had at after the illness has failed to respond to several drugs and least an history of malaria episode in the last 2 weeks before ineffective self-treatment. These practices increase morbid- the survey were extracted for this study having applied the ity and mortality in addition to contributing to possible emer- weighting factor. gence of drug resistance among under-five children in Nigeria (Okonkwo, Akpala, Okafor, Mbah, & Nwaiwu, 2001; WHO/UNICEF, 2003). Data Analysis Meanwhile, studies have shown that existing interven- tions could prevent many deaths among children if they are Having obtained the data set and extracted the eligible presented for appropriate and timely care (Jones et al., 2003). respondents, the data were analyzed using STATA 12 soft- The WHO estimates that seeking prompt and appropriate ware. The analysis involved three stages. The first stage is Kolawole and Asaolu 3 univariate analysis, at this stage, mothers’ background char- (prompt) of onset of symptoms and (b) treatment after acteristics such as age, marital status, religion, education, 24 hr (delay). place of residence, and so on, were examined. The bivariate analysis involved comparison and testing for significance Result of the Study between two variables such as mothers place of residence and type of treatment sought, mothers’ education and type of The Table 1 below presents the sociodemographic characteris- treatment sought, and so on. The third stage involved the tics of the respondents. Majority of the mothers are within the multivariate analysis that further analyzed the relationships age 25 and 39 (64.1%) while 95.1% of them are married with between independent and dependent variables. At this stage, shared religious affiliation as Christian (43.1%) and Muslim logistic regression models were used based on the selected (54.9%). Almost half (46.5%) of the women had no education, variables that were significant at the bivariate level. while 31.0% and 22.5% had primary and post secondary edu- Therefore, the following regression models were devel- cation, respectively. By occupation, more than half (67.3%) of oped to predict the likelihood of medical and prompt treat- the mothers were working at the time of the survey. About half ment of malaria. (49.2%) of the respondents are within the lower wealth index. Also, three quarter (75.1%) of the respondents lives in the Model 1. (Model built with socioeconomic factors and type of rural area as one quarter of their counterparts lives within the treatment sought) urban centers (24.9%). By region of residence, 22.0%, 30.0%, 14.0%, and 17.2% of the women lives in North-East, North-  P  log = ab + Xb + Xb + Xb ++  X , West, South-East, and South-South, respectively, while others   11 22 33 nn 1-P   lives in North-Central (8.3%) and South-West (8.5%), respec- where P is probability of accessing medical treatment for tively. More than half (54.1%) of the children received medi- malaria, a is the intercept, b s are the slopes, X is respon- cal treatment; about one third (27.6%) received traditional or i 1 dents’ religion, X is respondents’ level of education, X is home-based treatment whereas about one fifth received no 2 3 respondents’ occupational status, X is respondents’ place of treatment during the recent episode of malaria. In addition, residence, X is respondents’ wealth quintile, and X is more than half (52.7%) of the mothers delayed in seeking 5 6 respondents’ barrier to access health care facilities (n = 6). medical treatment for their children while less than half (47.3%) of their counterparts sought prompt medical treat- Model 2. (Model built with selected significant socioeconomic ment for their children. In assessing barrier to access health factors and delay in accessing health care) care, findings showed that about one third (31.9%) of mothers had no barrier, one fifth (21.0%) had permission as a con-  P  log = a + bX + bX + bX + +b X , straint, and more than one tenth (14.5%) had permission and   11 22 33 nn 1-P   money as a barrier, while 23.3% and 9.3% of the rest had per- where P is the probability of accessing prompt treatment, a is mission/money/distance/transportation as a barrier in access- the intercept, b s are the slopes, X is respondents’ wealth ing health care facilities. 1 1 index, X is respondents’ place of residence (n = 2). The Table 2 below presents the bivariate analysis of the All the analysis was done at 95.0% significance level (p relationship between mothers’ socioeconomic characteris- -value, < 0.05). tics, type of treatment sought, and delay in seeking treatment. From the table, findings revealed no significant relationship between marital status (χ = 11.32, p > .05) and type of treat- Measurement of Some Variables ment sought. Across all ages (χ = 16.40, p < .05), tendency •• Malaria: Fever was used as a proxy for malaria. to seek medical treatments increases consistently with age of According to the NDHS, fever is the main symptom mothers. The proportion of never married (65.1%), wid- of malaria, the proportion of febrile children in the owed, or divorced women (66.3%) who sought medical population is a proxy for assessing malaria preva- treatment for their children is 10% point greater than the pro- lence, and any reduction in the malaria disease burden portion of their married women (53.6%) counterparts. should lead to a reduction in the overall prevalence of Findings on mothers’ age (χ = 1.96, p > .05) and marital fever (NPC & ICF Macro, 2009) status (χ = 3.70, p > .05) show no significant relationship •• Type of treatment: Type of treatment was accessed in with delay in seeking treatment. Overall, 47.3% of mothers three ways: (a) no treatment, (b) home/traditional received prompt treatment for their children against their treatment, and (c) medical treatment at second level of counterparts (52.7%) who delayed in seeking treatment for analysis (Note: level of treatment was dichotomized their children. By marital status, less than half of never mar- at the third level of analysis into: 1. Medical treat- ried mothers (41.4%) and married mothers (47.3%) treat ment, 0. Otherwise). their children promptly within 24 hr of onset of symptoms as •• Delays in seeking treatment: Delay in treatment was against more than half (57.2%) of widowed/divorced moth- categorized into two: (a) treatment within 24 hr ers who treat their children promptly. 4 SAGE Open Table 1. Percentage Distribution of Respondents by Also, there exists a significant relationship between reli- 2 2 Sociodemographic Characteristics. gion (χ = 216.24, p < .05), education (χ = 257.55, p < .05), 2 2 occupation status (χ = 21.88, p < .05), wealth index (χ = Variables Frequency % 207.08, p < .05), type of residence (χ = 18.56, p < .05), Age region of residence (χ = 350.82, p < .05), and type of treat- 15-24 1,015 25.6 ment sought for malaria. The proportion of Christian moth- 25-34 1,935 64.1 ers who sought medical treatment (66.2%) for their children 35-40+ 1,018 10.3 is about 20% point greater than the proportion of their Current marital status Muslim (44.6%) counterparts who sought medical treatment Never married 120 3.0 for their children. Meanwhile, of those who sought medical Married 3,771 95.1 treatment, less than half (48.4%) of Christian mothers and Widow/divorced 77 1.9 46.2% of Muslim mothers sought prompt medical treatment Religion as against more than half (51.8% vs. 53.5%) of their counter- Christian 1,713 43.1 parts who delayed in seeking treatment. Islam 2,177 54.9 Type of treatment and delay in seeking treatment varies Others 78 2.0 consistently with mothers’ level of education: 69.0% for Level of education mothers with secondary education and above, 59.0% for No education 1,846 46.5 those with primary education, and 49.0% for those with no Primary 893 22.5 education. The percentage of mothers who did not seek any Secondary+ 1,229 31.0 treatment or sought treatment at home/traditional places is Occupational status 10% point lower among mothers with primary (12.6% and Not working 1,299 32.7 27.9%) education compared with their counterparts without Currently working 2,669 67.3 any education (25.8% and 32.5%). Although not significant, Wealth index Lower 1,954 49.2 but the proportion of mothers who gave prompt malaria Middle 765 19.3 treatment to their children increased consistently with level Upper 1,249 31.5 of education: 44.8% versus 55.2% of mothers with no educa- Place of residence tion; 47.3% versus 52.7% of those with primary education; Urban 987 24.9 and 50.4% versus 49.6% of those with secondary or post sec- Rural 2,981 75.1 ondary education sought prompt malaria treatment and Region delayed treatment, respectively, for their children. North-Central 330 8.3 By occupational status, 56.7% of working mothers against North-East 872 22.0 48.8% of non-working mothers received medical treatment North-West 1,189 30.0 for their children while 17.3% and 26.0% of working moth- South-East 555 14.0 ers as against 20.3% and 31.0% of non-working mothers South-South 682 17.2 received no treatment and home/traditional treatment for South-West 340 8.5 their children. Meanwhile, the proportion of mothers with Type of treatment prompt malaria treatment increase slightly with occupational No treatment 723 18.2 status: 47.8% for working mothers versus 46.0% for non- Medical treatment 2,148 54.1 working mothers. Traditional/others 1,097 27.6 Also, more than half, 59.5% and 68.2%, of mothers within Delay in seeking treatment the middle and higher wealth index against 43.0% of those No delay (within 1,306 47.3 within the lower wealth index sought medical treatment for 24 hr) their children. Of those who sought treatment, larger percent- Had delay (>24 hr) 1,457 52.7 age of mothers (57.9%) in the lower wealth index delayed as Barrier to access health care No problem 1,265 31.9 against 45.0% and 50.1% of their counterparts within the Permission 836 21.0 middle and higher wealth index that delayed in seeking treat- Permission/money 575 14.48 ment for malaria. Meanwhile, 58.7% versus 52.6% of urban Permission/money/ 925 23.3 and rural women sought medical treatment, respectively, distance while the percentage of rural women who delayed in seeking Permission/money/ 367 9.3 treatment is about 10% point greater than the percentage of distance/transport their urban counterparts that delayed in seeking medical Total 3,968 100.0 treatment. By region of residence, more than half of the mothers in Source. Author’s work; Data computed from 2008 Nigeria Demographic and Health Survey. the South-East (71.9%), South-South (66.3%), North-Central Kolawole and Asaolu 5 Table 2. Sociodemographic Factors Associated with Type of Treatment Sought and Delays in Seeking Treatment for Childhood Malaria. Delay in treatment (after Type of treatment (%) detecting symptom) No Traditional/ No delay (24 Has delay (2 2 2 Region treatment home Medical Total χ hr) days+) Total χ Age <24 197 (19.4) 304 (30.0) 514 (50.6) 1,015 16.396** 318 (46.3) 369 (53.7) 687 1.968 25-34 330 (17.1) 494 (25.5) 1,111 (57.4) 1,935 646 (46.6) 740 (53.4) 1,387 35-40+ 196 (19.2) 298 (29.3) 524 (51.5) 1,018 341 (49.6) 347 (50.5) 688 Total 723 (18.2) 1,097 (27.6) 2,148 (54.1) 3,968 1,306 (47.3) 1,457 (52.7) 2,762 Marital status Never married 15 (12.2) 27 (22.7) 78 (65.1) 220 11.324 37 (41.4) 52 (58.6) 88 3.700 Married 699 (18.5) 1,053 (27.9) 2,020 (53.6) 3,772 1,235 (47.2) 1,380 (52.8) 2,614 Widow/divorced 9 (12.1) 17 (21.6) 51 (66.3) 77 34 (57.4) 26 (42.6) 60 Total 723 (18.2) 1,097 (27.6) 2,148 (54.1) 3,968 1,306 (47.3) 1,457 (52.7) 2,762 Religion Christian 168 (9.8) 411 (24.0) 1,134 (66.2) 1,713 216.239** 601 (48.2) 646 (51.8) 1,246 0.803 Islam 540 (24.8) 666 (30.6) 971 (44.6) 2,177 680 (46.5) 781 (53.5) 1,461 Others 14 (18.1) 20 (25.6) 44 (54.1) 77 25 (45.8) 30 (54.2) 55 Total 723 (18.2) 1,097 (27.6) 2,148 (54.1) 3,968 1,306 (47.3) 1,457 (52.7) 2,762 Level of education No education 476 (25.8) 601 (32.5) 770 (41.7) 18.46 257.552** 540 (44.8) 665 (55.2) 1,205 6.701 Primary 113 (12.6) 249 (27.9) 531 (59.5) 893 294 (47.3) 328 (52.7) 622 Secondary+ 135 (11.0) 247 (20.1) 847 (69.0) 1,229 472 (50.4) 464 (49.6) 935 Occupational status Not working 262 (20.2) 403 (31.0) 635 (48.8) 1,299 21.885** 395 (46.0) 464 (54.0) 858 0.818 Currently working 461 (17.3) 694 (26.0) 1,514 (56.7) 2,669 911 (47.8) 993 (52.2) 1,904 Wealth index Lower 459 (23.5) 654 (33.5) 841 (43.0) 1,954 207.084** 531 (42.1) 731 (57.9) 1,262 29.111** Middle 117 (15.3) 193 (25.3) 455 (59.5) 765 300 (55.0) 246 (45.0) 546 Upper 148 (11.8) 250 (20.0) 852 (68.2) 1,249 475 (49.7) 480 (50.3) 955 Residence Urban 186 (18.9) 221 (22.4) 580 (58.7) 987 18.555** 383 (52.5) 347 (47.5) 730 10.876** Rural 537 (18.0) 876 (29.4 1,568 (52.6) 2,981 923 (45.4) 1,109 (54.6) 2,032 Region North-Central 41 (12.3) 91 (27.5) 199 (60.2) 331 350.824** 85 (37.1) 144 (62.9) 229 98.818** North-East 289 (33.1) 212 (24.2) 372 (42.6) 872 332 (52.2) 304 (47.8) 636 North-West 259 (21.8) 408 (34.3) 522 (43.9) 1,189 336 (44.1) 427 (55.9) 763 South-East 58 (10.5) 98 (17.6) 399 (71.9) 555 278 (65.3) 148 (34.7) 426 South-South 52 (7.6) 178 (26.1) 452 (66.3) 682 201 (40.5) 294 (59.5) 495 South-West 24 (7.1) 112 (32.8) 204 (60.1) 340 74 (34.5) 140 (65.5) 214 Total 723 (18.2) 1,097 (27.6) 2,148 (54.1) 3,968 1,306 (47.3) 1,457 (52.7) 2,762 Barriers to access HCF No barriers 225 (17.8) 297 (23.5) 743 (58.7) 1,265 79.827** 430 (46.4) 497 (53.6) 927 3.363 Permission 110 (19.2) 133 (23.1) 332 (57.7) 575 276 (47.3) 308 (52.8) 583 Permission/money 142 (17.0) 233 (27.9) 461 (55.1) 836 190 (44.6) 236 (55.4) 426 Permission/money/ 166 (17.9) 277 (30.0) 482 (52.1) 925 313 (49.4) 321 (50.6) 634 distance Permission/money/ 80 (21.9) 157 (42.8) 130 (35.3) 367 97 (50.3) 95 (49.7) 192 distance/transport Total 723 (18.2) 1,097 (27.6) 2,148 (54.1) 3,968 1,306 (47.3) 1,457 (53.7) 2,762 Note. HCF = health care facilities. **p, .05 (at 95% significance). (60.2%), and South-West (60.1%) sought medical treatment treatment for their children. Meanwhile, North-East (21.7%) for their children, while about one third of them in the North- and North-West (33.1), across all regions, signify a region East (24.2%), North-West (34.3%), North-Central (27.5%), with higher percentage of children without any treatment and South-West (32.8%) received either home or traditional during the illness. 6 SAGE Open As the numbers of difficulties faced in seeking treatment Finally, the likelihood of seeking medical treatment increase (57.7% for permission; 55.1% for permission and among mothers with four different barriers or difficulties money; 52.1% for permission, money, and distance; and combined (permission, money, distance, transport) is consis- 35.3% for permission, money, distance, and transportation), tently and significantly less (OR = 0.53; p < .05; CI = [0.38 the percentage of women who sought medical treatment for - 0.75]) when compared with their counterparts with either their children decreases, respectively. Also, the proportion of barriers/difficulties with permission (OR = 1.12; p > .05; CI mothers whose children received prompt treatment varies = [0.88 - 1.45]); barriers/difficulties with permission and consistently with numbers of difficulties encountered. money (OR = 0.84; p > .05; CI = [0.69 - 1.14]); or barriers/ The Table 3 below presents the odds ratio (OR) of the difficulties with permission, money, and distance (OR = general binary logistic regression for the likelihood of receiv- 0.86; p > .05; CI = [0.69 - 1.08]); as well as those without any ing medical and prompt treatment for children aged 12 to 59 barrier/difficulties. months who had malaria within 2 weeks preceding the sur- vey. The logistic regression was built with two models by Discussion of Findings selecting all mothers’ socioeconomic factors that have a sig- nificant relationship with type of treatment and delay in This study examined mothers’ socioeconomic differentials treatment at the bivariate level of analysis. The first model and management of childhood malaria using the 2008 NDHS therefore examined the likelihood of receiving medical treat- kids recode data set. Overall, 3,968 children had fever 2 ment with the selected mothers’ socioeconomic factors while weeks before the survey with majority of them within the age the second model examined the odds of giving prompt treat- bracket 12 to 35 months. Averagely across all ages, exactly ment with the selected significant socioeconomic factors at half of the children received treatment from medical centers, the bivariate level of analysis having controlled for region of about one third received treatment at home or traditional residence. health providers while about one fourth of the rest received Findings from logistic regression at this multivariate level no treatment at all. Meanwhile, against the fourth key ele- of analysis showed that the odds of seeking medical treat- ment of RBM strategy of accessing appropriate and adequate ment for children by their mothers vary proportionally with treatment within 24 hr of onset of symptoms, a little more level of education. Mothers with no education (OR = 0.62; than half of the mothers delayed beyond 24 hr before seeking p < .05; CI = [0.47- 0.81]) and primary education (OR = treatment for their children. In line with D’Souza’s (2003) 0.67; p > .05; CI = [0.67- 1.14]) are less likely to seek medi- research findings, delay in seeking treatment could be influ- cal treatment for their children compared with their counter- enced by past experience with similar illnesses which moti- parts with secondary education and above. Mothers within vate mothers to play a “waiting game” to see if the illness the middle (OR = 0.77; p < .05; CI = [0.59 - 1.00]) and lower subsides on its own, particularly in situations where the cost wealth index (OR = 0.49; p < .05; CI = [0.37 - 0.64]) are of care is an inhibitory factor (D’Souza, 2003). significantly less likely to seek medical treatment; as they are Urban mothers were found to have better chance of giving also less likely to seek prompt treatment (OR = 0.91; p > .05; their children medical and prompt treatment during malaria CI = [0.98 - 1.76] vs. OR = 0.81; p > .05; CI = [0.62 - 1.05]) illness than their rural mother counterparts. Also, greater per- for their children when compared with mothers within the centage of children within South-East, South-South, North- higher wealth index. Central, and South-West regions received medical treatment Meanwhile, the logistic regression at this level found no when compared with other regions. Conversely, greater per- significant relationship between mothers’ occupational status centage of mothers in the North-East, North-West, and and likelihood of seeking medical and prompt treatment for North-Central have the highest proportion of children with childhood malaria. However, findings showed that the odds fever whose treatment were delayed or were not treated at al of seeking medical treatment among mothers who were not or treated at home with traditional herbal medicine. These working (OR = 0.88; p > .05; CI = [0.57 - 0.88]) is less when findings are in line with Guyatt and Snow’s (2004), Kofoed compared with that of their counterparts in the working class et al.’s (2004), and Müller et al.’s (2003) research findings, category. Furthermore, Islamic mothers (OR = 0.72; p < .05; which concluded that malaria treatments are rarely sought at CI = [0.55 - 1.71]) and those in the other religion (OR = 0.98; health care facilities and are most often inappropriate or p < .05; CI = [0.14 - 2.27]) are significantly less likely to take delayed. their children for medical treatment compared with their The significant relationship found between religion, med- Christian counterparts. ical choice of treating malaria, and prompt treatment of Also, the odds of giving medical treatment (OR = 0.34; malaria corroborate earlier findings by Adamu (2001), Addai p > .05; CI = [1.07 - 1.69]) as well as prompt treatment (OR (2000), and Adetunji (1996), as this study revealed that = 0.82; p > .05; CI = [0.63 - 1.06]) among mothers in the Islamic mothers and those in the other religion are signifi- rural area are significantly less when compared with the odds cantly less likely to give medical and prompt treatment to of giving medical treatment as well as prompt treatment their children during malaria illness when compared with among mothers in the urban centers. their Christian counterparts. Kolawole and Asaolu 7 Table 3. General Binary Logistic Regression Models 1 and 2 for the Likelihood of Receiving Medical and Prompt Treatment for Children Aged 12 to 59 Months who had Malaria within 2 Weeks Preceding the Survey. Type of treatment received (medical treatment) Delay in accessing medical treatment (no delay) Model 1 Model 2 Selected variables Odds ratio (SE) p value 95% CI Odds ratio (SE) p value 95% CI Socioeconomic factors Level of education Secondary+ RC None 0.62 (0.09) .001** [0.47 - 0.81] Primary 0.88 (0.12) .334 [0.67 - 1.14] Wealth index Higher class RC RC Middle class 0.77 (0.10) .049** [0.59 - 1.00] 0.91 (0.20) .065 [0.98 - 1.76] Lower class 0.49 (0.07) .000** [0.37 - 0.64] 0.81 (0.11) .107 [0.62 - 1.05] Occupation status Working RC Not working 0.88 (0.08) .158 [0.74 - 1.05] Religion Christianity RC Islam 0.72 (0.08) .004** [0.57 - 0.88] Others 0.98 (0.28) .940 [0.55 - 1.71] Place of residence Urban RC RC Rural 0.34 (0.16) .011** [1.07 - 1.69] 0.82 (0.11) .131 [0.63 - 1.06] Barriers to in access HCF No constraint RC Permission 1.12 (0.15) .346 [0.88 - 1.45] Per/money/ 0.86 (0.09) .186 [0.69,- - 1.08] Per/money/distance 0.84 (0.11) .355 [0.69 - 1.14] Per/money/distance/ 0.53 (0.09) .000** [0.38 - 0.75] transport Note. Standard errors are in parenthesis. Model 1 = Model built with significant socioeconomic factors and type of treatment; Model 2 = Model built with selected significant socioeconomic factors and delays in accessing health care. CI = confidence interval; RC = reference category; HCF = health care facilities. **p, .05. In line with earlier studies by Pérez-Cuevas et al. (1996) malaria for their children. In addition, mothers’ wealth index and WHO/UNICEF (2003), which associate maternal literacy showed a significant relationship with type of treatment and mothers’ education with utilization of health care facili- sought and delay in seeking treatment. Mothers within the ties, this study also revealed that type of treatment and prompt middle and lower wealth index are significantly less likely to treatment of malaria varies monotonically with mothers’ level seek medical treatment; as they are also less likely to seek of education. Mothers with no education or with primary edu- prompt treatment for their children when compared with cation are less likely to seek medical and prompt treatment for their counterparts within the higher wealth index. their children compared with their counterparts with second- Furthermore, findings revealed that larger percentages of ary education or more. Efforts therefore need to be intensified urban mothers sought medical treatment for their children on health education with emphasis on the importance of iden- when compared with their counterparts in the rural areas. tifying vital malaria signs and giving prompt and appropriate The odds of giving medical treatment and prompt treatment care to febrile children within 24 hr of onset of the symptoms among mothers in the rural area was found to be significantly as advocated by WHO (2004). less when compared with the odds of giving medical treat- Also, this study showed that the proportion of mothers ment and prompt treatment among mothers in the urban cen- with prompt malaria treatment increased slightly with occu- ters. In addition, our findings showed that rural mothers are pational status. That is, mothers who are currently working more likely to delay in seeking treatment compared with are more likely to seek medical and prompt treatment of their urban counterparts. These findings are in line with the 8 SAGE Open studies conducted by Adeyemi (2000), Mekonnen and associated with medical and prompt treatment of malaria, Mekonnen (2002), Sabitu (2004), and UNFPA (2002, 2004), investing in women’s education through free education as which concluded that there are differences in utilization of well as intensive campaign to motivate them to go for higher health care facilities and maternal health care services level of education will be a worthwhile effort. Higher educa- between urban and rural areas. tion will enhance their wealth index and occupational status Findings on barrier or difficulties in accessing health care which will in turn have a positive influence on their ability to facilities and prompt treatment revealed a significant relation- care for children. ship in line with research findings by Hill et al. (2003), Mermert and Nsabagasanyi (2002), and Namusobya (1998), where they Limitation of the Study concluded that lack of finance for medical consultation and treatment, distance from health care facilities, and so on, are The study make use of a secondary data obtained from the important barriers to accessing health care facilities. Therefore, 2008 Nigeria Demographic and Health Survey, which is a these research findings also concluded that difficulties/barriers nationally representative data, and the author was not oppor- to access health care facilities significantly decrease medical tune to get the data in its natural settings. Thus, there are and prompt treatment of malaria in children. some limitations as predetermined by the data in terms of the questionnaire design and variable measured. For instance, mothers’ knowledge of severity of malaria sickness as well Conclusion and Policy as perceived benefit of prompt initiation of treatment was not Recommendation measure and therefore cannot be measured by this study. Having used both bivariate and multivariate level of analysis, Also, cases of missing values and high non-response rate are findings from this study concluded that mothers’ socioeco- common in the data set, and this was responsible for some nomic characteristics and barriers to access health care facili- variation in the row totals in the “Analysis” section. ties are significant factors militating against medical and prompt treatment of malaria in Nigeria. As revealed by this Declaration of Conflicting Interests study, about 50% of febrile children are never seen within The author(s) declared no potential conflicts of interest with respect health care facilities. They are either treated at home or not to the research, authorship, and/or publication of this article. treated at all. Therefore, appropriate and prompt use of health care facilities for treatment of malaria within 24 hr of onset of Funding symptoms are critical to the successful achievement of the The author(s) received no financial support for the research and/or United Nation’s Millennium Development Goal 4, which authorship of this article. calls for a two thirds reduction in child mortality by 2015. Although, National Policy on Malaria Diagnosis and References Treatment (Federal Ministry of Health, 2005, 2010) pro- motes the treatment of uncomplicated malaria at home with Adamu, Y. M. (2001, July). Spatio-temporal analysis of maternal mortality in Kano State. Paper presented to the Department of artemisinin-based combination therapies (ACTs). However, Geography, Bayero University Kano, Nigeria. it is disappointing that many people did not know about Addai, I. M. (2000). 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U., & Faculty of Social Sciences, Obafemi Awolowo University, Ile-Ife. Nwaiwu, O. (2001). Compliance to correct dose of chloroquine in uncomplicated malaria correlates with improvement in the Asaolu Olugbenga Stephen is a public health specialist currently condition of rural Nigerian children. Transactions of the Royal working with the Association for Reproductive and Family Health, Society of Tropical Medicine & Hygiene, 95, 320-324. as the senior monitoring and evaluation officer on the U.S. Agency Olaogun, A. A., Ayandiran, O., Olasode, O. A., Adebayo, A., & for International Development (USAID)-funded 5-year LOPIN- Omokhodion, F. (2005). Home management of childhood Region 1 project in Nigeria.

Journal

SAGE OpenSAGE

Published: May 20, 2016

Keywords: social sciences; under-five; mortality; demographics; early childhood; education; socioeconomic; childhood; malaria; Nigeria

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