Despite the availability of a safe and effective vaccine for over 50 years, measles remains a leading cause of death among young children in developing countries.
This study assessed the knowledge and home treatment of measles by caregivers of children under 5 years.
Abebi community, Ibadan, Oyo State, Nigeria.
A descriptive cross-sectional study of 509 caregivers of children aged 6 months to 5 years in a semi-urban community in Ibadan was conducted using a multi-stage sampling method. An interviewer administered structured questionnaire was used to collect information on socio-demographic characteristics, knowledge of aetiology, main symptoms and signs, and home treatment of measles. Chi-square test and logistic regression were used to explore associations at 5% level of significance.
Most of the caregivers were females (96.3%), married (86.1%) and were the biological parents of the children (90.9%). More than half had good knowledge of the cause (59.7%) and main symptoms and signs (52.8%) of measles. However, the composite knowledge was good in 57.6% of caregivers. Over half (54.4%) of the caregivers reported that their children ever had measles. Majority (91.3%) of caregivers whose children had measles gave home treatment, while 24 (8.7%) sought treatment from health facilities alone. There was a significant association between caregivers’ educational status, age, tribe and marital status and their knowledge of measles; however, tribe was the only significant predictor of knowledge after regression analysis. Caregivers from other tribes were 3.3 times more likely to have good knowledge of measles than Yoruba caregivers. Caregivers who were 35 years and older compared to those younger than 35 years (OR: 0.625; 95% CI: 0.425–0.921) and those who were not currently married compared to those married (OR: 0.455; 95% CI: 0.273–0.758) had lower odds of having good knowledge of measles, respectively.
Home treatment by caregivers of children with measles is high. Health education on the cause, prevention and treatment of measles should be provided for caregivers.
Measles also known as rubeola is an acute, highly communicable viral exanthematous disease caused by a virus.
Measles has also been rated as the fifth leading cause of childhood mortality.
Factors that predispose to burden of measles morbidity and mortality include poor immunisation coverage, malnutrition, cultural habits that influence health-seeking behaviour and early age of occurrence of infection.
Home management of diseases is influenced by caregivers’ knowledge of the aetiology, symptoms and signs including prevention and treatment of the disease.
This study was a community-based cross-sectional survey.
The study was carried out in Abebi, a community located in Ibadan Northwest Local Government Area (LGA), Oyo State. Oyo State is one of the 36 states of Nigeria and is located in the southwestern region of the country. The population of the state is about 5.5 million.
Abebi, the site of the study, is located in Ward 6 of Ibadan Northwest LGA. The population of the community is estimated to be 14 871 persons.
This study was a community-based cross-sectional survey of caregivers of children aged 6–60 months residing in selected households. Caregivers were either mothers or any other relative who was a major care provider and was able to give details of the child’s immunisation and health history. A minimum sample size of 455 caregivers was estimated using Leslie Fischer’s formula for sample size calculation with a population of 14 871, a 95% confidence interval, a margin of error of 4.5% and a 50% prevalence of home treatment for measles.
Multi-stage sampling was used to select eligible caregivers. In the first stage, Ibadan North-East LGA was selected from the five LGAs in Ibadan municipality by balloting. The second stage was the selection of Ward 6 (Alawo or Abebi Ward) from the 11 wards in the LGA by balloting. In the third stage, one settlement Abebi was selected from the 21 in Ward 6 by balloting. All the 68 compounds and 627 houses in Abebi settlement were visited. In each house, one eligible household was selected by balloting if there was more than one household in the house. The final stage was the selection of the index child where a household had more than one child between ages 6 and 60 months. The use of all 627 houses was predicated on the assumption that there are approximately four to five households in each house and that there would be a household with a child under 5 years of age.
A structured interviewer administered questionnaire was used to obtain information on socio-demographic characteristics of the index child and caregiver, knowledge of cause, signs and symptoms of measles, immunisation history and type of treatment given.
The questionnaire was adapted by the authors from extensive literature review
The primary outcome for this study was the use of home treatment for under-five year old children with measles by caregivers, while the secondary outcome was caregivers’ knowledge of measles infection. The domains of knowledge assessed were as follows: ‘knowledge of cause of measles’ and ‘knowledge of the signs and symptoms of measles’. The composite knowledge ‘overall knowledge of measles’ was also obtained from the two domains assessed. The responses to the knowledge questions were ‘yes’, ‘no’ and ‘I don’t know’. Every correct response to a question scored 1 point, while every incorrect response or ‘I don’t know’ scored 0 point. ‘Knowledge of cause of measles infection’ was assessed with 14 questions with a maximum obtainable score of 14 points, while ‘knowledge of symptoms and signs of measles’ was assessed with 16 questions with a maximum obtainable score of 16 points. The maximum obtainable score for ‘overall knowledge’ was 30 points. The mean ± SD knowledge scores were computed for ‘knowledge of cause of measles infection’ (8.2 ± 3.9), ‘knowledge of symptoms and signs’ (8.5 ± 2.1) and ‘overall knowledge’ (15.6 ± 4.2). Respondents whose scores were equal to or greater than the mean scores were categorised as having ‘good knowledge’, while those with scores less than the mean score were categorised as having ‘poor knowledge’.
The WHO classification for ‘probable case of measles’ which is ‘any child with fever of 38.3 °C, generalized maculopapular (non-vesicular) rash lasting ≥ 3 days and cough, coryza (runny nose), or conjunctivitis (red eyes)’ was used as the case definition for measles in this study.
‘Index child’: this was a child less than 5 years old for which information on measles was sought from the caregiver. The index child was selected by balloting only in households where more than one of the children less than 5 years has had measles infection.
‘Home treatment’ for measles was said to have occurred where a caregiver administered any form of remedy (orthodox or unorthodox) to an under-five year old child with measles (probable case definition) for more than 2 days at home without visiting a health facility.
The immunisation status of the children was determined by caregivers’ reports and confirmed with the immunisation cards.
‘Occupational groups’ included the unskilled (e.g. farmers, traders and housewives), semi-skilled (carpenters and welders) and skilled (e.g. teachers, nurses and civil servants) groups.
For the purpose of analysis, educational status was categorised into ‘below secondary education’(no formal and primary education) and ‘secondary education and above’; marital status into ‘currently married’ and ‘not currently married’, ethnicity into ‘Yoruba’ and ‘others’ and relationship with child into ‘parental relationship’ and ‘other relationships’.
Data obtained were analysed using Statistical Package for the Social Sciences (SPSS) version 22 software package.
Ethical approval was obtained from Oyo State Ministry of Health Ethical Review Board and informed consent was obtained from the caregivers after providing information about the study and confirming that they fully understood the study objectives. Confidentiality of the respondents was also ensured.
A total of 520 questionnaires were administered of which 509 were completed and used for the analysis, giving a response rate of 97.9%. Eleven (2.1%) of the respondents did not complete their interviews.
The socio-demographic characteristics of the caregivers and children are shown in
Socio-demographic characteristics of caregivers of under-five year old children.
Variable ( |
Frequency | Percentage | ||
---|---|---|---|---|
Male | 19 | 3.7 | ||
Female | 490 | 96.3 | ||
Less than 35 years | 363 | 71.3 | ||
35years and above | 146 | 28.7 | ||
Yoruba | 474 | 93.1 | ||
Ibo | 25 | 4.9 | ||
Hausa | 8 | 1.6 | ||
Others |
2 | 0.4 | ||
Islam | 296 | 58.2 | ||
Christianity | 213 | 41.8 | ||
Single | 20 | 3.9 | ||
Married | 438 | 86.1 | ||
Divorced | 43 | 8.4 | ||
Widowed | 8 | 1.6 | ||
Parents | 463 | 90.9 | ||
Mother’s sister | 14 | 2.8 | ||
Father’s sister | 19 | 3.7 | ||
Grandparent | 13 | 2.6 | ||
None | 49 | 9.6 | ||
Primary | 132 | 25.9 | ||
Secondary | 299 | 58.7 | ||
Tertiary | 29 | 5.8 | ||
Unskilled | 64 | 12.6 | ||
Semi-skilled | 401 | 78.8 | ||
Skilled | 44 | 8.6 | ||
Monogamous | 399 | 78.4 | ||
Polygamous | 110 | 21.6 |
, Benin & Efik.
All 509 respondents had heard (were aware) of measles infection. Concerning the knowledge of causes of measles, 304 (59.7%) caregivers had good knowledge of the cause of measles (see
Causes of measles indicated by caregivers (
Caregivers’ knowledge of the cause, main symptoms and signs of measles and overall knowledge about measles.
Knowledge ( |
Frequency | Percentage |
---|---|---|
Poor | 205 | 40.3 |
Good | 304 | 59.7 |
Poor | 240 | 47.2 |
Good | 269 | 52.8 |
Poor | 216 | 42.4 |
Good | 293 | 57.6 |
Regarding the main symptoms and signs of measles, 269 (52.8%) of the caregivers had good knowledge of the main symptoms and signs of measles (see
Main symptoms and signs of measles indicated by caregivers (
The overall knowledge of measles expressed by the caregivers (see
Probable cases of measles 1 year prior to or during the study period were reported among 277 (54.4%) children less than 5 years of age by their caregivers even though more than three-quarters (387, 76.0%) of the children had received measles immunisation.
Out of the 277 caregivers whose children had measles, 253 (91.3%) administered home treatment and only 24 (8.7%) opted for treatment from health facilities. Some of the treatments administered at home included palm oil (81.8%), palm wine (77.5), antibiotics (75.1%) and tepid sponge (68.4%) (see
Home treatment and remedies used by caregivers of children under the age of five in the home treatment of measles.
Home treatment ( |
Frequency | Percentage |
---|---|---|
Yes | 253 | 91.3 |
No | 24 | 8.7 |
Paracetamol | 216 | 85.4 |
Palm oil on the body | 207 | 81.8 |
Palm wine for bathing | 196 | 77.5 |
Antibiotics | 190 | 75.1 |
Tepid sponge | 173 | 68.4 |
Black soap mixture for bathing | 168 | 66.4 |
Oral herbs | 162 | 64.0 |
Drugs for malaria | 157 | 62.1 |
Bitter leaf for drinking and bathing | 157 | 62.1 |
Local bin | 127 | 50.2 |
Cream or lotion | 116 | 45.8 |
Eye drops | 100 | 39.5 |
Shea butter mixture | 76 | 30.0 |
Breast milk in the eye | 73 | 28.9 |
, multiple response.
Caregivers’ educational status, age, tribe and marital status were significantly associated with their knowledge of measles. However, the tribe of the caregivers was the only significant predictor of their knowledge following logistic regression. Caregivers from other tribes were 3.3 times more likely to have good knowledge of measles compared to those of Yoruba tribe (see
Association between socio-demographic factors of caregivers and their knowledge of measles.
Variable ( |
Knowledge of measles |
Unadjusted odds ratio (95% CI) | Adjusted odds ratio (95% CI) | |||
---|---|---|---|---|---|---|
Poor ( |
Good ( |
|||||
% | % | |||||
Male |
11 | 57.9 | 8 | 42.1 | 1.912 (0.756–4.836) | 1.428 (0.512–3.986) |
Female | 205 | 41.8 | 285 | 58.2 | ||
Below secondary education |
90 | 49.7 | 91 | 50.3 | 1.586 (1.099–2.288) |
1.344 (0.899–2.008) |
Secondary education and above | 126 | 38.4 | 202 | 61.6 | ||
Below 35 years |
142 | 39.1 | 221 | 60.9 | 0.625 (0.425–0.921) |
0.751 (0.486–1.161) |
35 years and above | 74 | 50.7 | 72 | 49.3 | ||
Islam |
136 | 45.9 | 160 | 54.1 | 1.413 (0.987–2.024) | 1.351 (0.931–1.959) |
Christianity | 80 | 37.6 | 133 | 62.4 | ||
Yoruba |
209 | 44.1 | 265 | 55.9 | 3.155 (1.352–7.365) |
3.254 (1.364–7.762) |
Others | 7 | 20 | 28 | 80 | ||
Parent |
193 | 41.7 | 270 | 58.3 | 0.715 (0.390–1.311) | 1.148 (0.564–2336) |
Other | 23 | 50 | 23 | 50 | ||
Currently married |
174 | 39.7 | 264 | 60.3 | 0.455 (0.273–0.758) |
0.567 (0.318–1.009) |
Not currently married | 42 | 59.2 | 29 | 40.8 |
CI, confidence interval.
, Statistically significant relationship on bivariate analysis (unadjusted odds ratio).
, Statistically significant relationship on regression analysis (adjusted odds ratio).
, Reference category.
There was no significant association between the socio-demographic characteristics and home treatment of measles by the caregivers. However, a higher proportion of caregivers with poor knowledge of measles (93.2%) compared to those with good knowledge (89.9%) administered home treatment though this association was not statistically significant (see
Association between caregivers’ socio-demographic factors and knowledge of measles infection with home treatment of measles.
Variable | Home management of measles |
Unadjusted odds ratio (95% CI) | |||
---|---|---|---|---|---|
Yes ( |
No ( |
||||
% | % | ||||
Male | 12 | 85.7 | 2 | 14.3 | 0.548 (0.115–2.605) |
Female | 241 | 91.6 | 22 | 8.4 | |
Below secondary education | 108 | 93.9 | 7 | 6.1 | 1.809 (0.725–4.515) |
Secondary education and above | 145 | 89.5 | 17 | 10.5 | |
Below 34 years | 150 | 90.9 | 15 | 9.1 | 0.874 (0.368–2.072) |
35 years and above | 103 | 92.0 | 9 | 8.0 | |
Islam | 151 | 90.4 | 16 | 9.6 | 0.74 (0.305–1.794) |
Others | 102 | 92.7 | 8 | 7.3 | |
Yoruba | 228 | 91.2 | 22 | 8.8 | 0.829 (0.184–3.735) |
Others | 25 | 92.6 | 2 | 7.4 | |
Parent | 226 | 91.5 | 21 | 8.5 | 1.196 (0.335–4.274) |
Other | 27 | 90.0 | 3 | 10.0 | |
Currently married | 207 | 90.8 | 21 | 9.2 | 0.643 (0.184–2.2.46) |
Not currently married | 46 | 93.9 | 3 | 6.1 | |
Poor | 110 | 93.2 | 8 | 6.8 | 1.538 (0.635–3.725) |
Good | 143 | 89.9 | 16 | 10.1 |
CI, confidence interval.
This study assessed the knowledge of measles among caregivers of children aged 6–60 months and the practice of home treatment for their children’s measles.
More than half (59.7%) of the caregivers from our study had good knowledge of the cause of measles, with over a third (36.3%) of them knowing that measles was caused by a microorganism. This was in contrast to another study conducted in eastern Nigeria, where almost all respondents were aware of measles but none of them knew the cause of measles.
Concerning the knowledge of caregivers about main symptoms and signs of measles, over half (52.8%) of the caregivers of our study had good knowledge. However, complications of measles such as sore tongue or red lips (94.5%), blurred vision (73.4%), inability to eat (83.3%), mouth ulcer or blister (77.6%) and ear discharge (40.75) were regarded as main symptoms and signs of measles. This has significant implication on the morbidity and mortality outcome of measles. Classifying complications as signs and symptoms of early infection means that children are treated at home longer than they should and consequently present late for treatment in health facilities. This potentially leads to the disabling complications (visual, auditory, mobility and learning disability) and case fatality associated with measles.
The overall knowledge of measles (57.6%) among caregivers of less than 5-year-old children reported in our study is higher than the knowledge (16.2%) reported among mothers of less than 5-year-old children in Konduga and Auno districts in Northern Nigeria.
In this study, only 8.7% of the caregivers took their children to the health facility within 48 hours. Conversely, measles was managed at home by 91.3% of the caregivers in this study. In Northern Nigeria, 69% of mothers were reported to have administered home treatment to their under-five year old children.
According to the WHO, any case of measles should be reported to a health facility within 48 h as part of control strategy.
In this study, associations between socio-demographic characteristics and home management of measles were not significant. Olaogun et al. in 2006 also reported non-significant association between educational level and home treatment of febrile illness.
A review study on eradication of measles using Nigeria as a case study reported the following reasons for the persistent prevalence of measles in Nigeria: cultural factors, health system and governmental factors.
A major limitation of this study was the use of a questionnaire whose construct was not validated. The non-existence of a standardised instrument may be responsible for the varying knowledge reported by other researchers. However, this study attempted to make the instrument better by including wide range of responses that were generally perceived as cause, symptom and treatment of measles infection. Furthermore, a critical review of the questionnaire by academics involved in measles surveillance provided some content validity to the questionnaire.
Knowledge of measles was good among half of the caregivers; however, there are still some misconceptions about the causes and symptoms and signs. Caregivers also delay in taking their children to health facilities and administer some harmful home remedies. Information on the cause and identification of measles and other vaccine-preventable diseases rather than on only completing the immunisation schedule should be intensified at antenatal, immunisation and postnatal clinics. The need for early presentation at the health facility to prevent complications from diseases should also be intensified through health education.
The authors acknowledge Oluwafisayomi Adegbola-Ayoola for her contribution during the research.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
All authors helped in conceptualising and designing the study. Data collection was coordinated by O.U. and O.I. Quantitative data analysis was conducted by O.U. and O.A. All authors contributed to the draft of the final manuscript, and revised and agreed on the final version.
Socio-demographic data
What is your age (last birthday in years)? ____________________ Sex
Male Female What is your religion?
Christianity Islam Traditional Others (specify)____________________ What is your tribe?
Yoruba Ibo Hausa Others (specify) ____________________ What is your highest level of education?
None Primary education Secondary education Polytechnic education University education Other post-secondary education (specify) ____________________ What is your marital status?
Single never married Single cohabiting Married Separated Divorced Widow/widower What is your occupation?
Housewife Farmer Trading Artisan Professional Others (Please specify) ____________________ Relationship of caregiver with child
Parent Mother’s sister Father’s sister Grandparent Foster parents Others (please specify) ____________________ Family type
Monogamous Polygamous Monthly income level of caregiver ____________________
Who owns the house you live in?
Personal Rented Family house What type of house do you live in? (select only one)
How many rooms do you occupy in the house? ____________________ How many children do you have? ____________________
Male Female Did all your children receive complete immunisation?
Yes No If No to Q. 14, how many did not receive complete immunisation?
Male Female
Housing type
Storey
Bungalow
i.
Duplex
ii.
Flats
iii.
Winged apartments
Knowledge of cause, symptoms and signs, and complications of measles
16.
Measles is common among:
Yes
No
I don’t know
a.
Children less than 9 months
b.
Children between 9 months and 5 years
c.
Children between 6 and 18 years
d.
Adults
e.
Elderly
f.
Foreigner
g.
Others (specify)
17.
What causes measles?
Yes
No
I don’t know
a.
Exposure to heat
b.
Infection with microorganism/virus
c.
Spiritual attack
d.
Mosquito bite
e.
Physical contact with infected person
f.
Inhalation of bad air
g.
When a child is malnourished
h
Contaminated water or food
i.
Dirty environment
j.
Bushy environment
k.
Overcrowding in a poorly ventilated room
l.
Lack of immunisation for measles
m.
Seasonal change/change in weather
n.
When child is teething (tooth eruption)
o.
Others (specify)
18.
The main symptoms of measles are
Yes
No
I don’t know
a.
High body temperature
b.
Cough
c.
Running nose/catarrh
d.
Redness of eyes
e.
Rashes on the body
f.
Inability to eat
g.
Vomiting
h
Diarrhoea
i.
Mouth ulcer/blister
j.
Fast breathing
k.
Ear discharge
l.
Noisy breathing
m.
Peeling skin
n.
Sore tongue/red lips
o.
Blurred vision
p.
Nightmares
q.
Others (specify)
Prevalence of measles infection and immunisation rates
Has any of your children had measles before?
Yes No How many of your children have had measles before? _____________________
Male Female
Did your children with measles receive measles immunisation?
Yes No If yes to Q25, where did they receive immunisation? ________________________________________ If yes to Q. 22, is there immunisation card for confirmation?
Yes No If no to question Q. 22, why did they not receive immunisation?________________________________________
21
How many of your children have had measles in the last
one year?
Male
Female
Total
25.
How did you know your child has measles?
Yes
No
a.
Cough
b.
Vomiting
c.
Fever
d.
Redness of eyes
e.
Runny nose/catarrh
f.
Rashes
g.
Mouth ulcer/blister
h
Noisy breathing
i.
Pain and swelling behind the ear
j.
Malnutrition/severe weight loss
k.
Convulsion
l.
Rapid breathing
m.
Swelling of body and or feet
n.
Difficulty in breathing
o.
Unconscious/lethargic
p.
Chest in drawing
q.
Others (specify)
Management of measles in children by caregivers at home
In your child with measles, did you give any home treatment?
Yes No
Did you seek further treatment outside your home?
Yes No If yes to Q. 28, for how many days did you treat at home before seeking further treatment outside the home? ____________________
Where did you first seek for treatment for your child outside after home treatment?
Chemist Herbalist Church Mosque Relatives Friends Hospital Others (specify) ____________________
27.
If yes to Q. 29, what did you do?
Yes
No
a.
I gave oral herbal concoction
b.
I tepid sponged
c.
I gave paracetamol
d.
I gave drugs for malaria
e.
I gave palm wine for bathing/drinking
f.
I used eye drops
g.
I used herbal concoction for bathing
h
I used urine mixture in the eye
i.
I used body cream/lotion
j.
I used palm oil on the body
k.
I gave urine mixture for drinking
l.
I used palm oil in the eye
m.
I gave antibiotics
n.
I used breast milk in the eye
o.
I used bitter leaf for drinking and bathing
p.
I used black soap mixture for bathing
q.
I used shea butter mixture on the skin
r.
I gave local gin for drinking
s.
Others (specify)
30.
What was the reason for seeking help outside the home?
Yes
No
a.
Mouth ulcers
b.
Dehydration
c.
Redness of eye with pains
d.
Ear discharge
e.
Severe fever
f.
Inability to eat or drink
g.
Noisy breathing
h
Pain and swelling behind the ear
i.
Malnutrition/severe weight loss
j.
Convulsion
k.
Rapid breathing
l.
Swelling of body and or feet
m.
Difficulty with breathing
n.
Unconscious/lethargic
o.
Chest in drawing
p.
Others (specify)
32.
Why did you choose to seek treatment where you did from Q. 31?
Yes
No
a.
It was not expensive
b.
It was the nearest place
c.
Workers were more friendly
d.
Pain and swelling behind the ear
e.
Staff are always available
f.
Workers are more sympathetic
g.
They counsel and listen to patients
h
Drugs are always available
i.
It was recommended by a relative (specify)
j.
It was recommended by a friend
k.
I did not want my child to be injected
l.
Others (specify)
33.
At the place you first sought for treatment in Q. 31, what was done?
Yes
No
a.
Told to use herbs for drinking
b.
Told to use herbs for bathing
c.
Told to fast and pray for child
d.
Told to use palm wine for drinking and bathing
e.
Told to use body cream/ointment
f.
Told to use eye drops
g.
Told to use oral drug
h
Told to take rest
i.
Others (specify)
34.
If you first sought treatment in a hospital, what drugs were you given?
Yes
No
a.
Eye drop
b.
Ear drop
c.
Cough syrup
d.
Antibiotics
e.
Skin (calamine ) lotion
f.
Paracetamol
g.
Vitamin A
h
I was not given any medication
i.
Others (specify)
Outcome of the measles infection
If you sought care in the hospital, was the child admitted?
Yes No If yes to Q. 35, for how many days was your child on admission? ____________________ What was the outcome of the treatment given?
Alive Dead
37.
In your child with measles, which of these problems/symptoms did the child have?
Yes
No
a.
Dehydration
b.
Noisy breathing
c.
Ear discharge
d.
Convulsion
e.
Lethargy
f.
Chest in drawing
g.
Inability to eat/drink
h.
Difficulty in breathing
i
Others (specify)
38.
If you did not seek for help in hospital, how did you know that your child was healed from measles infection?
Yes
No
a.
The skin peeled
b.
Fever reduced
c.
The child was able to eat
d.
Mouth ulcers/blisters were healed
e.
Purging/diarrhoea stopped
f.
Breathing became normal
g.
Eyes were no longer red
h.
Ear discharge stopped
i.
Others (specify)
Thank you.