https://orcid.org/0000-0001-5195-4793
Abstract
: Child mortality from infectious diseases is still high in Nigeria. Appropriate illness concepts (IC), healthseeking behaviours (HSB) and breastfeeding practices (BFP) of mothers are critical to addressing child mortality arising from infectious diseases. This study seeks to determine the relationship between mothers’ formal education and IC, HSB, BFP, family structure and parity, in market women in rural Plateau State, Nigeria, with a view to making policy recommendations from the data. A total of 993 women from three rural markets in Plateau State were effectively recruited and studied. A structured questionnaire was used to elicit information from the women. Appropriate descriptive and inferential statistical tools were used for data analyses. About 70% of the women had received some formal education while 62.4% of them reported an infectious disease in their homes within the month prior to the study. Exclusive breastfeeding for more than 6 months was practiced by 78% of the population. Almost all the mothers had appropriate IC (99%) and proper HSB (92%). Whereas length of formal education was significantly and negatively correlated with age of mother (r = −0.525; p < 0.001), number of children (r = −0.213; p < 0.001) and family structure (r = −0.494; p < 0.001), it was not significantly correlated with IC, HSB or BFP. Informal modes of education are apparently critical to the dissemination of messages related to proper IC, HSB and BFP among rural market women, and are thus recommended.
1. Introduction
Women occupy an important place in the development of any nation, as (especially in economically developing countries) they are often responsible for planning and preparing the meals of the family and caring for the children. Consequently, any health programme in such societies, which is planned to succeed, must necessarily place a high premium on the role women play in the health of nations(Osubor et al., Citation2006). Consequently, the illness concepts and health-seeking behaviour (HSB) of women directly speak to that of their families. Wrong illness concepts usually will result in inappropriate HSB(Ejike, Citation2014). A basic understanding of the cause of diseases, particularly infectious diseases, is a prerequisite to appropriate disease-preventive behaviours and appropriate decision-making in the event of a disease. Given that illness concepts are often coloured by cultural norms(Beiersmann et al., Citation2007; Maneze et al., Citation2015; Webair & Bin Ghouth, Citation2014), and that the burden of deaths from infectious diseases is still very high in tropical countries such as Nigeria(World health Organization (WHO), Citation2017), it is important that mothers, especially rural market women, have the right illness concepts and HSB.
Statistics on child-deaths from around the world are staggering. A 2022 report indicates that there were 5.4 million deaths (per 1000 live births) in children aged less than 5 years in 2019, and that 80% of those deaths occurred in sub-Saharan Africa and south Asia Sharrow et al., (Citation2022). It also estimated that if the 2019 rates are maintained, there will be as much as 3.8 million under-5 deaths by 2030. Earlier, the United Nations Children’s Fund (UNICEF) reported that of the 5.6 million under-5 deaths in 2016; and India and Nigeria alone accounted for 32% of the figure. One child in thirteen in sub-Saharan Africa died before age 5; and in Nigeria the figure stood at 104 (110 for a male child and 98 for a female child) per 1000 live births. Only six countries in the world had child mortality rates in excess of 100 per 1000 live births, and all six are in sub-Saharan Africa(UNICEF, Citation2017). These deaths are often preventable using simple means such as breastfeeding. The World Health Organisation (WHO) and UNICEF recommend that children should be breastfed exclusively for the first 6 months of life, and that even after the introduction of complementary feeding, breastfeeding should be continued till the child is 2-years old(World health Organization (WHO), Citation2001). This recommendation is informed by the knowledge that exclusively breastfed children have a better immune system and are usually free from diseases such as diarrhoea, pneumonia, gastroenteritis, coughs, and otitis media (World health Organization (WHO), Citation2001),Ezeh et al. (Citation2015),Ikeako et al. (Citation2006),Ogbo et al. (Citation2015). Though the policies of government in Nigeria in the post-military era have emphasised investments in maternal and child health (for example, using instruments such as the National Health Policy, Ward Health System, and the Baby Friendly Hospital Initiative), the degree of adoption of local and international recommendations vary, often depending on locality. Yet the adoption and implementation of such recommendations are critical to meeting critical goals such as the Sustainable Development Goals SDGs; Koffi et al., (Citation2017), especially SDG goals 1–4. Little is known about the degree to which rural market women adopt exclusive breastfeeding in Nigeria, especially as the bulk of the studies on the subject are conducted in urban centres. This is despite the fact that the majority of women in Nigeria live in rural areas.
One of the roles of education in a society is the provision and enhancement of enlightenment. It enhances the health and well-being of individuals because it reduces the need for health care, the associated costs, promotes and sustains healthy lifestyles and positive choices (Feinstein et al., Citation2006). Ordinarily, an educated person will have the capacity for rational thought and would make the right choices on matters of health (Maneze et al., Citation2015). It has been reported that the decision to seek health depends on a variety of factors including a woman’s educational status (Nayab, Citation2018). Indeed, the role of education in ensuring that mothers perceive illnesses properly and act rationally when they occur appear commonsensical. However, even among educated Nigerians, poor illness concepts and HSB are reported to be prevalent (Ejike, Citation2014). Unfortunately, there is yet, no study on the effect of education on illness concepts, HSB and breastfeeding practices in Nigerian rural market women. This study was designed to provide information in this regard, and therefore studied the subject in market women from three rural contiguous Local Government Areas in Plateau State, Nigeria. The results will (hopefully) be useful in public health policy development and action.
2. Subjects and methods
2.1. Subjects
Market women in three Local Government Areas (LGAs) of Plateau State, Nigeria, namely, Bokkos LGA, Barkin Ladi LGA and Mangu LGA (Figure ) were randomly recruited from the major local markets in the said LGAs. The aim of the study was explained to the women in their local languages and those who gave informed oral consents were recruited. All those who were willing to participate in the study were enrolled. The only exclusion criterion was the woman had to be married and have a child who is younger than 5 years. A total of 993 women (266 women in Bokkos, 343 in Barkin-Ladi, and 384 in Mangu) were effectively recruited and studied.
Figure 1. Study locations on the map of Plateau State, Nigeria.
2.2. Methods
Self-reported age at last birthday was recorded for each woman. For a few who were not sure when they were born, they were asked to lead the investigator(s) to any educated age-mate of theirs in the market. From the age of such an age-mate, the age of the subject was estimated and recorded. A structured, pre-tested and validated questionnaire was used to collect information from the women on relevant variables such as length of time spent in formal educational institutions as a pupil/student, number of children, family structure, illness concepts, health-seeking behaviour, and breastfeeding practices. For illness concepts, HSB and breastfeeding practices, only respondents who responded “YES” to the question “Has any of your children suffered from cough, diarrhea, malaria, typhoid, or ear infections in the last one month?” had their data analysed.
To assess their illness concepts, the respondents were asked a single question (immediately after the question above) thus: “What do you believe causes the above diseases?” They were required to choose from the options: (a) Microorganisms (b) Spirits/Charms (c) Both. To assess their HSB, they were asked the single question: “If your child has any of the above diseases, where would you normally seek help?” The option provided for them were (a) Hospital/Clinic, (b) Patent medicine dealer/Chemist, (c) Traditional healer, (d) Prayer houses/Churches/Mosques. Subjects were allowed to choose more than one option, if that was their practice. For breastfeeding practice, they got the question: “How do you normally breastfeed your children?” The options made available to them were: (a) Exclusive up to 3 months, (b) Exclusive up to 6 months, (c) Exclusive for more than 6 months), and (d) not exclusive.
No honoraria was given to participants; they were however offered free health counseling on a variety of health issues.
2.3. Statistical analyses
Continuous data are reported as means ± standard deviations and the differences between relevant groups were separated using one way ANOVA. Frequency counts were used and percentages calculated where necessary. For such categorical data, the Chi square test and the Fischer’s exact test were used to check for significant differences. To assess the correlation between duration of formal education and the other studied variables, the Pearson’s product moment correlation coefficients were calculated. All data analyses were carried out using IBM-SPSS Statistics version 20 (IBM Corp., Armonk, NY).
3. Results
The mean age of the studied women was 43.0 ± 12.8 years (44 ± 14.1 years in Bokkos, 46.1 ± 13.5 years in Barkin Ladi, and 44.0 ± 13.1 years in Mangu). The market women spent a mean time of 6.5 ± 4.6 years in formal educational institutions while their mean number of children was 5 ± 3. Similar patterns were observed for age, duration of formal education, number of children and family structure, irrespective of the location of the mothers studied (Table ). Approximately 55–60% of the mothers were 45 years old or younger, and about 70% of the mothers had some formal education (even though only about 5% of the entire population went beyond the secondary school). The modal number of children was 4–6 children and the monogamous family was clearly the dominant family structure. Considering the semblance in patterns, subsequent analyses were carried out in the entire population without disaggregating the data based on Local Government Area of Residence.
Table 1. Age and distribution of the studied market women, with respect to relevant characteristics
A total of 62.4% of the studied mothers reported an infection/infectious disease in their household within 1 month prior to the study. Necessarily therefore, only data from this subset, totalling 620 mothers, were further analysed. It is important to note that the characteristics of the subjects in this sub-set (age, length of formal education, family size and structure) were comparable to that of the parent population. As much as 78% of the population reported breastfeeding their children exclusively for more than 6 months. Interestingly, when compared to those who reported not breastfeeding exclusively at all, there was no significant difference (P > 0.05) in age of the mothers, length of formal education, number of children and family structure between both groups. Only mothers who reported breastfeeding exclusively for only 3 months were found to have significantly fewer children (P < 0.05) compared to those who did not breastfeed exclusively (Table ).
Table 2. Breastfeeding practice, illness concepts and health-seeking behaviours (related to infectious diseases) of the studied market women
Almost all the mothers (99%) believed infectious diseases were caused by microorganisms (Table ). Mothers who however believed that infectious diseases were caused by both biological and spiritual factors were found to be significantly older than those who correctly identified microorganisms as the cause of infectious diseases. Not surprisingly, none of those who believed infectious diseases were caused by both biological and spiritual factors had any formal education.
A clear majority of the mothers (92%) reported seeking medical help during an infectious disease episode in a hospital or health centre; that is, had appropriate health-seeking behaviours (HSB). Only 1.7% of the mothers reported seeking healthcare in the church or visiting a traditional medicine practitioner; that is, had wrong HSB (Table ). Interestingly though, there was no significant difference (P > 0.05) in age of the mothers, length of formal education, number of children and family structure between those with wrong HSB and those with appropriate HSB.
There were significant negative correlations (r = —0.213 to—0.525; P < 0.001) between length of formal education and age of mothers, family structure and parity (Figure ). Clearly, older women spent less time in formal educational institutions, and the more educated the mother, the fewer the children she has and the more likely it will be that the family will be monogamous. There was an insignificant negative correlation (r = —0.051 to—0/064; P > 0.05) between length of formal education, on the one hand, and both illness concepts and HSB, on the other hand (Figure ). Finally, breastfeeding practice was positively but insignificantly (P > 0.05) correlated with length of formal education of mothers (Figure ). It is important to note here that 1 represents the right illness concept or HSB (in Figure ), while 4 represents exclusive breastfeeding beyond 6 months (in Figure ), indicating that as length of formal education increased the wrong concepts decreased, and exclusive breastfeeding beyond 6 months increased, albeit not significantly.
Figure 2. Correlations between length of mothers’ education and some relevant factors in the studied population of mothers.
4. Discussion
The finding that about a third (30%) of the mothers had no formal education is worrisome, given the known benefits of education on not just women but also on their families, especially their daughters. This level of illiteracy is higher than figures from the South of Nigeria, but nonetheless lower than figures from the most northern States in Nigeria where illiteracy and its adverse effects are still very high(Koffi et al., Citation2017). Consequently, only the roughly 70% of the studied market women who had post-primary school formal education can be considered functionally literate and educated.
The modal family size was 4–6 children and the monogamous family was clearly the dominant family structure. The correlation data suggests that the number of children is driven by length of formal education. It is usually a necessary fall-out of education that women desire to have fewer children. This is usually informed by their understanding of the economics of caring for large families (Åslund & Grönqvist, Citation2010; Kalil et al., Citation2012). An educated mother is more likely going to be more interested in appropriate nutrition, medication and education of her children and these are usually financially demanding. Given that family incomes are often fixed, smaller family sizes usually translates into a larger share of the resources per family member. Additionally, education delays marriage for the girl-child and reduces the number of years available to her for procreation (McCleary-Sills et al., Citation2015), such that even if the educated woman desired to have many children, she may not be able to have as many as her friends who married many years before her. The observation that the monogamous family was the modal family structure in the study area may be due to the fact that the population is predominantly Christian and Christianity encourages the practice of monogamy as a means of social organisation.
A total of 62.4% of the studied mothers reported an infection/infectious disease in their household within 1 month prior to the study. Clearly, infectious diseases are very prevalent in the study areas. This is not surprising as infectious diseases are a sad but daily experience in the tropics. The warm humid weather and the often poor hygienic environments in tropical countries present an opportunity for vectors to multiply and inflict serious healthcare challenges on the population. In fact, in 2016 alone, there were 216 million malaria cases worldwide and 90% of those occurred in the WHO Africa region alone (World health Organization (WHO), Citation2017)! In the same year, there were 445 thousand deaths from malaria and 91% of the deaths occurred in the WHO Africa region. In Nigeria, there were 57, 300,000 cases of malaria and 100, 700 deaths from the disease in the same year (World health Organization (WHO), Citation2017). The figures for other infectious diseases would also be staggering. This therefore calls for urgent action to address the situation. Such actions necessarily need to be driven by policies that are formulated with an understanding of the social contexts, belief-systems, and behaviours of the people, especially the women who are (often painfully) customarily saddled with the responsibility of cleaning the environment and caring for their children. Here one finds an appreciation of their breastfeeding practices, illness concepts and health-seeking behaviours important.
Breastfeeding is a validated means of preventing childhood illness due to infectious agents(World health Organization (WHO), Citation2001,Ogbo et al., Citation2015). It is therefore encouraging that as much as 78% of the population reported breastfeeding their children exclusively for more than 6 months. This is significantly higher than the 39% predominant breastfeeding practice reported among educated Nigerian women, and even the 60% recommended to meet development goals (Ogbo et al., Citation2015). One must however note that though exclusive breastfeeding is popular in the studied population, it may not be driven by length of formal education but rather by other factors, likely antenatal education. This is because the correlation coefficients show that though there was a positive correlation between exclusive breastfeeding practice and length of formal education, it was not significant statistically. Furthermore, since 99% reported appropriate illness concepts related to infectious diseases and 92% had appropriate HSBs, it is plausible that other less-formal systems of education (say antenatal education) may have contributed significantly to the reported high prevalence of exclusive breastfeeding beyond 6 months.
The finding that more than 90% of the market women had the right illness concepts, related to infectious diseases and also had appropriate HSB suggests that with a strengthened health system, many of the infectious diseases-related deaths can be avoided. This is so because the mothers clearly are properly aware of the causes of the diseases and where to seek medical attention. It is important to also note that the reported illness concepts and HSB were not as a result of the length of formal education received by the mothers as there was no significant correlation between both variables and the length of formal education. This disagrees with some other reports from Nigeria where uneducated mothers made poor healthcare choices for themselves and their children, relative to more educated ones(Ikeako et al., Citation2006; Uzochukwu et al., Citation2008). Furthermore, it signifies that some other form of education, likely informal- or quasi-formal education, may be responsible for the observed proper perception of infectious diseases causative agents and proper knowledge of where they should be managed. This thesis requires further study. Indeed, a study among formally educated Nigerians had reported abysmally poor illness concepts Ejike, (Citation2014); though with respect to chronic diseases). Formal education is however very important as it is seen that all those that reported that both biological and spiritual agents caused infectious diseases had no formal education at all.
The data re-enforces the need for girl-child education as it shows that educated women have the right illness concepts and HSBs. They also apparently understand the need for exclusive breastfeeding up to 6 months and are less likely to have more than 5 children. More importantly, the data suggests that a complementary informal education on health-related matters (especially for women who do not have formal education) is particularly critical in ensuring that women have the right illness concepts and HSB. These have significant implications for economic advancement at the family level and for national development. Health policies targeting breastfeeding and infectious diseases control should therefore emphasise informal means of passing information to mothers outside the walls of the classroom. Here, the use of the mass media, social media, faith-based organisations, trade associations, etc. to disseminate useful well-crafted health messages is advocated.
This study is limited by its dependence on self-reports to generate the data used to arrive at the conclusions reached by this study. Inherent in this is a possibility for biases that may have given the data some “false positives” or “false negatives”. It however could not have been possible to conduct a population wide cross-sectional study such as this without relying on self-reports. The fact that there was no incentive to lie for the mothers, also suggests that the data can be relied on as factual representation of the experiences of the mothers. Secondly, the study would have been more robust if all the Local Government Areas of Plateau State were studied. However, financial constraints made this impossible. This therefore warrants a cautious interpretation of the data as it is reflective of the situation with only market women in the studied LGAs. Again, the study would have benefitted from a detailed questionnaire eliciting more information from the women and using more formal research questions. Given the constraints mentioned earlier, this was not possible; furthermore the data obtained with the instruments used are sufficient to support the conclusions reached.
Irrespective of the above, the study is robust from the prism that an under-studied population, that in fact constitutes the majority, was targeted and studied. Women who attend local markets to buy and sell items (typically farm produce) are veritable representatives of the rural womenfolk who are often voiceless and rarely studied. Given that more Nigerians live in rural areas, studying market women gives a clear idea of the experiences of rural women in the study area. The use of a simple instrument to obtain information from the women also adds to the strengths of the study.
5. Conclusion
The relationship between length of mothers’ formal education, illness concepts, health-seeking behaviours and breastfeeding practices was studied in a population of market women in three LGAs in Plateau State, Nigeria (mean age: 43.0 ± 12.8 years). As much as 62.4% of the studied mothers reported an infection/infectious disease in their homes within the month prior to the study. Seventy-eight percent of the population reported breastfeeding their children exclusively for more than 6 months. Almost all the mothers (99%) had the right illness concepts while 92% of them had proper HSB. Whereas length of formal education was significantly and negatively correlated with age of mother, number of children and family structure, it was not significantly correlated with illness concepts, HSB or breastfeeding practice. Both formal and informal modes of education are required to ensure that mothers have the right illness concepts, health-seeking behaviours and breastfeeding practices.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
References
- Åslund, O., & Grönqvist, H. (2010). Family size and child outcomes: Is there really no trade-off? Labour Economics, 17(1), 130–10. http://dx.doi.org/10.1016/j.labeco.2009.05.003
- Beiersmann, C., Sanou, A., Wladarsch, E., De Allegri, M., Kouyaté, B., & Müller, O. (2007). Malaria in rural Burkina Faso: Local illness concepts, patterns of traditional treatment and influence on health-seeking behaviour. Malaria Journal, 6(1), 1–9. https://doi.org/10.1186/1475-2875-6-106
- Ejike, C. E. C. C. (2014). Biokemistri ‘ this stroke was sent … ’: Stroke-related illness concepts and attendant health-seeking behaviours of educated Nigerians. Biokemistri, 26(3), 69–75. https://www.ajol.info/index.php/biokem/article/view/113792
- Ezeh, O. K., Agho, K. E., Dibley, M. J., Hall, J. J., & Page, A. N. (2015). Risk factors for postneonatal, infant, child and under-5 mortality in Nigeria: A pooled cross-sectional analysis. BMJ Open, 5(3), 1–9. https://doi.org/10.1136/bmjopen-2014-006779
- Feinstein, L., Sabates, R., Anderson, T. M., Sorhaindo, A., & Hammond, C. Measuring the effects of education on he alth and civic engagement: 4. What are the effects of education on health? In: Proceedings of the Copenhagen Symposium [Internet]. 2006. p. 171–354: https://www1.oecd.org/edu/innovation-education/37425753.pdf
- Ikeako, L. C., Onah, H. E., & Iloabachie, G. C. (2006). Influence of formal maternal education on the use of maternity services in Enugu, Nigeria. Journal of Obstetrics and Gynaecology, 26(1), 30–34. https://doi.org/10.1080/01443610500364004
- Kalil, A., Ryan, R., & Corey, M. (2012). Diverging destinies: Maternal education and the developmental gradient in time with children. Demography, 49(4), 1361–1383. https://doi.org/10.1007/s13524-012-0129-5
- Koffi, A. K., Kalter, H. D., Loveth, E. N., Quinley, J., Monehin, J., & Black, R. E. (2017). Beyond causes of death: The social determinants of mortality among children aged 1-59 months in Nigeria from 2009 to 2013. PLoS One [Internet], 12(5), 1–22. http://dx.doi.org/10.1371/journal.pone.0177025
- Maneze, D., Digiacomo, M., Salamonson, Y., Descallar, J., & Davidson, P. M. (2015). Facilitators and barriers to health-seeking behaviours among Filipino migrants: Inductive analysis to inform health promotion. Biomed Res Int, 2015. https://doi.org/10.1155/2015/506269
- McCleary-Sills, J., Hanmer, L., Parsons, J., & Klugman, J. (2015). Child marriage: A critical barrier to girls’ schooling and gender equality in education. The Review of Faith & International Affairs, 13(3), 69–80. https://doi.org/10.1080/15570274.2015.1075755
- Nayab, D. (2018). Health-seeking behaviour of women reporting symptoms of reproductive tract infections. Pakistan Development Review, 44(1), 1–35. https://www.jstor.org/stable/41260701
- Ogbo, F. A., Page, A., Agho, K. E., & Claudio, F. (2015). Determinants of trends in breast-feeding indicators in Nigeria, 1999-2013. Public Health Nutrition, 18(18), 3287–3299. https://doi.org/10.1017/S136898001500052X
- Osubor, K. M., Fatusi, A. O., & Chiwuzie, J. C. (2006). Maternal health-seeking behavior and associated factors in a rural Nigerian community. Maternal and Child Health Journal, 10(2), 159–169. https://doi.org/10.1007/s10995-005-0037-z
- Sharrow, D., Hug, L., You, D., Alkema, L., Black, R., Cousens, S., Croft, T., Gaigbe-Togbe, V., Gerland, P., Guillot, M., Hill, K., Masquelier, B., Mathers, C., Pedersen, J., Strong, K. L., Suzuki, E., Wakefield, J., & Walker, N. (2022). Coussens S and members of the un inter-agency group for child mortality estimation and its technical advisory group. global, regional, and national trends in under-5 mortality between 1990 and 2019 with scenario-based projections until 2030: a systematic analysis by the un inter-agency group for child mortality estimation. The Lancet. Global Health, 10(2), e195–206. https://doi.org/10.1016/S2214-109X(21)00515-5
- UNICEF. Child mortality 2017. Unicef for every child. 2017;44.
- Uzochukwu, B. S. C., Onwujekwe, E. O., Onoka, C. A., Ughasoro, M. D., & Keiser, J. (2008). Rural-urban differences in maternal responses to childhood fever in south east Nigeria. PLoS One, 3(3), 1–8. https://doi.org/10.1371/journal.pone.0001788
- Webair, H. H., & Bin Ghouth, A. S. (2014). “This diarrhoea is not a disease.” local illness concepts and their effects on mothers’ health seeking behaviour: A qualitative study, shuhair, Yemen. BMC Public Health, 14(1), 1–8. https://doi.org/10.1186/1471-2458-14-581
- World health Organization (WHO). The optimal duration of exclusive report of an expert consultation. Rep an Expert Consult. 2001;March.
- World health Organization (WHO). World malaria report 2017. Geneva.