Objective. To assess Peruvian mothers' knowledge and recognition of pneumonia in children under 5 years of age, the mothers' attitude toward seeking medical help if they had a child with signs of pneumonia, and their perception of a Government of Peru pneumonia campaign.
Respiratory tract infections; children's health; health education; knowledge, attitudes, practice; Peru.
As of December 1998 Peru had 24 371 000 inhabitants, of whom 34.9% were below the age of 14 years, and only 4.5% were 65 years old or older (1). Of every 10 Peruvians, 7 live in cities, while 3 live in rural areas. Lima, Peru's capital, currently contains 29.1% of the total population and is the main pole of migrant attraction (2). In Peru, 75 000 mothers who are under 20 years of age give birth annually. From 1980 to 1995 the number of births per woman declined from 5 to 3.2 (3).
The infant mortality rate in 1999 was 43 per 1 000 live births (2), whereas in 1994 the mortality rate of children under 5 years of age was 74 per 1 000 (3). Acute respiratory infections (ARIs) are the main cause of morbidity and mortality in Peru among the general population. This is particularly true among children under 5 years of age and among the elderly. Pneumonia ranks first among health problems requiring attention in health centers and second among causes of mortality for children under 5 years old (4-6). The most vulnerable members of the population are children under 5 who live in poverty around the coastal cities, particularly Lima, which is the biggest coastal city and has the highest ARI incidence of any city in the nation (7).
In 1987, the Ministry of Health of Peru, with the support of the Pan American Health Organization (PAHO), the United Nations Children's Fund (UNICEF), and other international organizations, established the Acute Respiratory Infections Control Program (ARICP), with the purpose of preventing and controlling ARIs in children under the age of 5 years. Known as the Government pneumonia campaign (GPC), this program is still in operation to some degree. While the intrahospital mortality rate has shown an important decrease in recent years, the extrahospital mortality rate remains a serious problem (4). Among the health promotion programs used by the Peruvian Government to prevent death from pneumonia in children less than 5 years of age are the winter pneumonia campaigns, which have placed strong emphasis on respiratory infection control. Between 1999 and 2000, these campaigns were more aggressively carried out during the winter months, when deaths from pneumonia are usually higher. Regardless of when it was promoted, the central message of the government campaign was the same: "RESPIRACIÓN RÁPIDA, RÁPIDO AL CENTRO DE SALUD" ("RAPID BREATHING, RAPIDLY TO THE HEALTH CENTER") (8). This message was disseminated via television (TV), radio, posted announcements, and other media.
Rapid breathing and, to a lesser extent, chest retraction are the two signs that have been promoted from the inception of the GPC program as indicators of pneumonia to motivate people to take their children to the closest clinic. Among the main results of the ARICP or the GPC intervention was that 40% of homes had identified the pneumonia risk signs and had taken the children to clinics in a timely fashion, according to a 1998 UNICEF report (9). However, it is unknown how Peruvian mothers perceive pneumonia issues such as the seriousness of the sickness, its causes and signs, and what they should do when a child has pneumonia, as well as how the mothers perceive some elements of the Government pneumonia campaign (GPC) such as its central message and the means through which they received this message.
Pneumonia death reduction in children under 5 years of age has been shown to be possible by improving recognition of the signs by parents, earlier presentation of children with these signs to health care facilities or to trained community health workers, availability of antimicrobial agents at the primary health care level, and rational decisions by health care workers about the use of these agents (10-14).
Although programs to improve care-seeking for children under 5 years of age with life-threatening acute illnesses, including upper respiratory infections, have been conducted in the past, some were not evaluated or measured for effectiveness (15). Nevertheless, current health education interventions aimed at persuading mothers to seek medical help for children with pneumonia and other life-threatening illnesses seem to be effective in reducing pneumonia deaths in their children (11, 16-25).
To build a better understanding of mothers' reaction to child pneumonia, the World Health Organization (WHO) Child Health and Development Division has promoted focused ethnographic analyses based on qualitative research with small samples. Such analysis provides information on how families perceive and respond to pneumonia as well as what cultural factors affect care-seeking for children with signs of pneumonia (11, 12, 26-29).
This study had two main objectives: 1) to assess Peruvian mothers' knowledge of pneumonia, their perceptions of its causes, their ability to recognize the signs of pneumonia, and their behavior if they were to have a child with the signs and 2) to assess their memory of the central message used in the GPC, and the means through which they learned this message.
In addition to rapid breathing and chest retraction, which were the main signs promoted by the Government campaign, other signs are currently being emphasized and communicated to the public, by the nurses in the clinics and by pharmacists as well as on some of the pamphlets prepared for the GPC. These signs include fever, cough, and weakness.
MATERIAL AND METHODS
This observational study used a cross-sectional design. Two stages of assessment took place. In the first stage a set of openended questions was given to a group of 40 mothers for the purpose of helping define the questions for the larger, second stage. These initial questions concerned the mothers' knowledge and recognition of pneumonia as well as their behavior in case of having a child with signs of pneumonia.
In the second stage, using the responses from the first-stage group of mothers, a questionnaire was developed and used as the instrument for data collection with 501 mothers. This second-stage questionnaire included a set of 25 questions about knowledge and recognition of pneumonia, behavior in case of having a child with signs of pneumonia, and perception of the Government pneumonia campaign (GPC). A set of 7 questions about demographics was also included. These 32 questions offered the mothers a total of over 100 possible responses, ranging from 1 to 21 answers per question. The mothers took approximately 15 minutes to complete the questionnaire. Mothers were interviewed in Spanish by trained interviewers, and their responses were written in on the questionnaire.
The target population was mothers 18 years old or older with at least one child under 5 years old, who lived in an asentamiento humano ("human settlement," or HS) of the metropolitan area of Lima, Peru. An HS is a low-income community initially established "informally," that is, without formal title to the property.
The 40 mothers for the first stage of assessment were selected from the Huaycán HS. That HS is located in the Chaclacayo district, in the eastern zone of Lima, near the Carretera Central highway, 19 km from the city center of Lima, and close to the Peruvian Union University.
The second stage of assessment involved choosing 20 HSs where the finalized questionnaire would be administered. For that, we first worked with a list of Lima HSs that was provided by the Formalization Commission for Informal Property (FCIP) (Comisión de Formalización de la Propiedad Informal, or COFOPRI), which is in charge of registration, formalization, and filing for informal settlements. Four zones of the metropolitan area of Lima were identified: North, South, East, and Callao. Second, using random numbers generated by Microsoft Excel spreadsheet software (Microsoft Corporation, Seattle, Washington, United States of America), 20 HSs were selected: 6 from the North, 7 from the South, 6 from the East, and 1 from Callao. The number of HSs selected by zone was proportional to the number of housing lots in each zone. Third, using a house-numbered map for each selected HS, 20 houses were randomly chosen. Fourth, the interviewer team identified the selected house in situ and checked if that particular house met the inclusion criteria of having a mother 18 years or older with at least one child under 5 years old. If the house met the criteria, the interviewer proceeded with the interview. If not, the interviewer flipped a coin to select a house to the left or right of the original house, until the required number of homes was checked.
With a sample of 501 mothers and alpha set at .05, this study would have adequate power (0.80) using chis-quare analysis to detect relationships between mothers' perceptions of the GPC and their beliefs about pneumonia and seeking medical help for a child with pneumonia.
Two professors from the Peruvian Union University Theology and Public Health Department collected data in May 2000 for the first stage of assessment. For the second stage of assessment one of the co-authors of this paper (CAG) trained a team of senior public health students at Peruvian Union University to assist him with the data collection. Data for this section were collected from June through August of 2000. The interviewers visited the selected houses, checked whether or not they met the criteria, and proceeded with the interview. At the end of the interview the interviewer thanked the mother, put the questionnaire in its envelope, and sealed the envelope in the presence of the mother. All the questionnaires were delivered to the investigator, and the interviewer did not have access to them after that point. At the end of the data collection period 501 mothers had been interviewed.
Each team member carried identification indicating that the interviewer was a representative of the Pneumonia and Children Survey sponsored by the Peruvian Union University of Lima, Peru, and Loma Linda University of California.
The survey was authorized by the Ministry of Health of Peru through the Director of the Personal Health Division, who had responsibility for ARI control of the country.
The final data were entered using the SPSS version 9.0 statistical software package (SPSS Inc., Chicago, Illinois, United States of America). Descriptive statistics and cross-tabulations were used to analyze the data and to assess relationships. The chi-square test was used to test the significance of variables in the equation and to make comparisons.
Demographic information from the 501 mothers who were surveyed is presented in Table 1.
Knowledge about pneumonia
As is shown in Table 2, 83.6% of the mothers said that they knew what pneumonia is. When these mothers were given a list and asked to check what pneumonia is, only 24.4% chose the "strong cold" alternative. Most mothers (87.7%) believed that pneumonia is highly or very dangerous, and 58.7% believed that pneumonia is caused by a lack of parental care. In addition, weather change (52.7%) and cold temperature (51.5%) were indicated as causes. Only 28.9% of mothers reported that a virus or germ causes pneumonia.
Recognition of pneumonia
Table 3 shows the mothers' responses to recognition of pneumonia. Most mothers said they would recognize pneumonia if their child had rapid breathing (82.4%) or if the child had chest retraction (81.0%). The mothers also pointed to other, congruent signs such as panting, chest retraction when the child inhales, rapid heartbeat, fever, and appearance of weakness. Only 5.4% of the mothers said that they were not sure how to recognize the presence of pneumonia in their children.
Seeking medical help
In terms of seeking medical help, most mothers (94.6%) indicated that they would take their child to the closest health center and 64.5% to the doctor if they thought their child had pneumonia (Table 4). There were small percentages of mothers who said they would take other actions such as taking the child to a pharmacist, using medicinal herbs and herbal baths as well as using other alternative treatments or home remedies.
Mothers' perceptions of the Government pneumonia campaign
In this section of the questionnaire mothers were allowed to indicate more than one means through which they had received the message from the Government pneumonia campaign. Of the 57.1% of mothers who said they heard about the GPC, the majority of them (74.1%) said they heard it on TV, 53.5% said they were told at a clinic or hospital, 29.4% got it through posters put up in the clinics and on buildings in the city, 28% by radio, 26.6% by reading pamphlets, 7.3% from a friend or relative, and 5.9% through other means (e.g., flyers or by loudspeakers on cars).
When the interviewers invited the 501 mothers to recall the central message of the campaign, 347 of them (69.3%) could not recall it or did not respond. Only 154 (30.7%) of them gave some answer related to the message. Of these 154 mothers who were capable of recalling the message, most of their responses were associated with rapid breathing: 39 of them (25%) said "rapid breathing" directly, 16 (10%) said "panting," and 99 (65%) said "rapid breathing" combined with other signs. The actual message of the campaign was "RAPID BREATHING, RAPIDLY TO THE HEALTH CENTER."
As shown in Table 2, there was a relationship between mothers' report that they know what pneumonia is and having heard about the pneumonia campaign. Those that said they know what pneumonia is were more likely to report having heard about the pneumonia campaign.
There is a relationship between having heard about the pneumonia campaign and all listed pneumonia concepts, that is, the variables shown in Table 2 under "what pneumonia is" and "what causes pneumonia." Nevertheless, whether mothers heard about the pneumonia campaign was not related to their beliefs about what pneumonia is. There is no relationship between having heard about the pneumonia campaign and the mothers' report of how dangerous pneumonia is. Mothers who had heard about the pneumonia campaign were also more likely than mothers who had not heard about it to indicate that lack of care of parents or weather change were causes of pneumonia. Mothers who had not heard of the campaign were more likely to indicate that they did not know the cause of pneumonia.
As can be seen in Table 3, of 20 listed pneumonia signs, only 2 of them showed a significant relationship with having heard of the pneumonia campaign. There was a direct relationship between having heard about the pneumonia campaign and recognizing rapid breathing or chest retraction in the "upper stomach zone" as a sign of pneumonia. Finally, there was a direct relationship between the mothers' having heard of the campaign and reporting that they were likely to take the child to the doctor if they believed that the child had pneumonia (Table 4).
Mothers indicated the media through which they had learned about the Government pneumonia campaign: TV, radio, being told at the clinic, posted announcements, etc. Of interest is how the particular medium through which they had heard of the campaign was associated with their recognition of the signs of pneumonia that were emphasized in that campaign: rapid breathing and chest retraction in the "upper stomach zone." Using only mothers who had heard of the Government campaign through some source, we calculated contingency coefficients for these associations. The contingency coefficient is a statistic analogous to the correlation coefficient. It shows the strength of association between two categorical variables. We also attempted to assess which medium was most highly associated with recognition of each of the two signs, using logistic regression analysis. The results of all these analyses are shown in Table 5.
Based on the contingency coefficients, mothers who reported having heard of the campaign through TV or posted announcements were more likely to recognize both signs than were mothers who had not heard of the campaign through these media. Being told at the clinic or having heard of the campaign on the radio was related to increased recognition of rapid breathing only. For both logistic regressions, the more exposure to media, the more likely the mother was to recognize the signs of pneumonia. However, the only media exposure that independently predicted either sign was recognition of rapid breathing by having heard of the program through a clinic or hospital. We ran an additional test to see if mothers' believing that pneumonia comes from a virus was related to what they would do when they believed a child had pneumonia, but we found no relationship.
Of the 501 mothers surveyed, 16.4% said they either did not know what pneumonia is or they had never heard about pneumonia. Most of these Peruvian mothers (87.7%) believe that pneumonia is highly or very dangerous. The World Health Organization focused ethnographic studies suggest that in most cultures people distinguish between mild and severe ARIs (28). There were similar findings in Honduras, where mothers invariably considered pneumonia to be the most serious of the ARIs and said that children could die from it (27).
When asked about the causes of pneumonia, only 28.9% of the Peruvian mothers in our study said they believe that a virus or germ causes pneumonia, and few of them see poor nutrition as a cause of pneumonia. Peruvian mothers were influenced by their worldview regarding the perception of what causes pneumonia. The majority would feel responsible if their child had pneumonia. In many cultures there is a tendency to put the blame on the mother in cases of pneumonia in children (28). In our sample that responsibility is based on the belief that the cause of pneumonia is lack of care when the child is exposed to sudden weather change and/or to a cold temperature. The most commonly cited causes related to an external cold temperature are being exposed to cold air, removing a child's clothes when he or she is warm, exposing him or her to outdoor air in a sudden fashion, and bathing the child outdoors. Mothers also cited causes related to an internal cold temperature such as the intake of cold foods and drinks. Cold, as a cause of pneumonia, was also cited by Honduran mothers (27) and by rural Bolivian mothers (12). Finally, in this study mothers cited only natural causes. This contrasts with most cultural models, in which pneumonia in very young children is not generally attributed to natural causes (28).
UNICEF reported that in 1995 40% of Peruvian mothers were able to recognize pneumonia signs such as rapid breathing and chest retraction (9). Results from our study, done 5 years after the UNICEF one, show that over 80% of the mothers know about these two signs. Reasons for this large increase could be the effect of the GPC, previous experience of mothers with a pneumonic child (22.4% of the participants in this study had had a pneumonic child previously), health promotion in hospitals and clinics, and communication among neighbors and relatives. In contrast, in studies of perceptions of pneumonia signs, Ethiopian and Pakistani mothers did not recognize rapid breathing or chest retraction as serious signs of pneumonia (11, 25). Also, although Honduran mothers said that characteristic symptoms of pneumonia are breathing as if tired, pain in the chest, and high fever, none of these mothers mentioned chest retraction (27). The current Peruvian Government campaign emphasizes such signs of pneumonia as cough, fever, and weakness. However, when mothers in this survey were asked by interviewers to indicate signs of pneumonia, the mothers seldom indicated these ones from the newer Government campaign.
Most of the mothers in our study said that they would take their child to the closest clinic if they thought the child had signs of pneumonia. However, about 15% of mothers would use alternative methods such as talking to a pharmacist, treatment with medicinal herbs, and treatment with an herbal bath. Studies in two rural communities in Bolivia found that herbal teas were the most common remedies for ARI (12). In addition, in our study a small percent said that if they believed the child had pneumonia, they would use treatments such as garlic teas and rubbing the child with eucalyptus ointment or Vick's VapoRub salve. They also said that they might cover the children with a thick cloth or blankets to cause them to sweat. In 1997 and 1998 it was found that in the metropolitan area of Lima 33% of householders who had any illness consulted with traditional medicine specialists, motivated by lower cost, cultural habit, and more trust than in physicians (30). Gove and Pelto (28) have remarked that the perspective of causes of acute respiratory illness may influence decisions about where to seek care first, or when to shift from one type of care to another. If cold temperature was indicated as one important cause for pneumonia, then doing the opposite, making the child sweat or providing heat to the child, will bring health. Current research shows that such hydrotherapy resources as a spa, sauna, and other thermotherapeutic methods have been used effectively in the treatment of children with ARI and asthma (31).5However, to deal with a child who has signs such as rapid breathing and chest retraction, and who lives in poor conditions, virtually the only way to save his or her life is by getting an appropriate dose of antibiotics. Here, the mothers' perception of cause should play an important role in the selection of appropriate solutions by health personnel who are involved with the program. However, we did not find in our study any relationship between believing that pneumonia comes from a virus or a germ and what a mother would do with a child with signs of pneumonia.
It is interesting that only 3.2% of the mothers in our study said they would pass a rabbit over the child. This small percentage may indicate that the GPC and living in a modern city such as Lima are decreasing the use of some traditional cultural healing techniques.
Mothers heard about the GPC mainly through TV and through a clinic or hospital. It seems that the clinic or hospital is effective as a place for providing health information to mothers. The reasons may be past experience with pneumonia treated in the clinic, information or education from health workers, posters displayed in the facilities, or talks with other patients. Among other means used in the Government campaign that a group of mothers reported were the announcements through speakers mounted on cars and one-page flyers that were handed out. This finding seems to show the potential for pneumonia campaigns to use that kind of inexpensive advertising to reach communities and families.
It is also possible that mothers learned the signs and symptoms of pneumonia through means other than the Government campaign. These might have included having experience with a pneumonic child, taking him or her to the closest clinic, or receiving the message through flyers while visiting a clinic or hospital for some other sickness. In addition, other factors could facilitate learning, such as talks among neighbors, information from relatives, and even gossip. Carrying out studies on those factors could benefit future ARI and pneumonia campaigns and also build the skills of health workers to inform, educate, and communicate (8).
Finally, although the percentage of mothers believing they can recognize pneumonia through rapid breathing and chest retraction seems to have increased as compared to a UNICEF study done in 1995, there is still a sizable percentage of mothers who remain uninformed about pneumonia and its possible fatal consequences. Efforts need to continue to educate Peruvian mothers about the causes, recognition of the signs, and treatment of pneumonia. This study suggests that the GPC should make greater use of television and health centers, where most of the mothers receive medical attention and health information. Mothers should be encouraged to seek medical help when a child has any of the signs of pneumonia, and particularly in the winter months when the problems are more acute.
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Manuscripts received 8 June 2001. Revised version accepted for publication on 21 November 2001.
Conocimientos de madres peruanas sobre la neumonía en niños menores de 5 años y capacidad para reconocer sus síntomas
Objetivo. Evaluar los conocimientos de madres peruanas sobre la neumonía y el reconocimiento de sus síntomas en niños menores de 5 años, la actitud de las madres hacia la búsqueda de asistencia médica cuando un hijo presenta signos de neumonía y percepción de las madres en torno a una campaña del Gobierno del Perú contra la enfermedad.
1 Universidad Peruana Unión, Lima, Peru.
2 Loma Linda University School of Public Health, Department of Health Promotion and Education, Loma Linda, California, United States of America. Send correspondence to: Naomi Modeste, Loma Linda University School of Public Health, Loma Linda, California 92350, United States of America; fax: (909) 558-4087; telephone: (909) 558-4741; e-mail: email@example.com
3 Loma Linda University Graduate School, Department of Psychology, Loma Linda, California, United States of America.
4 Loma Linda University School of Allied Health Professions, Cardiopulmonary Sciences, Loma Linda, California, United States of America.
5 Preisler B, Falkenbach A, Kluber B, Hofmann D. [The effect of the Finnish dry sauna on bronchial asthma in childhood]. Pneumologie 1990;44(10): 1185-1187. (From Medline Express®, 1998, Abstract No. 91125999.)