Abstract
Background
Pneumonia is one of the lower respiratory tract infections. It is defined as an infection of the lung tissue. Delayed treatment of pneumonia in under-five children is health care Seeking after 24 h from the recognition sign of pneumonia. Delayed, health seeking for sick children with pneumonia is associated with high morbidity/mortality of under-five children.
Objective
To identify the determinants of delay in treatment-seeking for under-five pneumonia among caregivers at public health facilities in Waliso Town, Ethiopia, 2025.
Methods
A facility based un-matched case- control study among 381(127 case and 254 control) with 1:2 ratios were conducted from December 10, 2024 – February 10, 2025 among under-five children at public health facility in Waliso Town, Ethiopia. Consecutive and systematic sampling technique was employed to select cases and controls respectively. Data were collected by face-to-face interview and entered into Epi info version 7.25 and exported to SPSS version 25 for analysis. Factors having p-value < 0.25 in the bivariable analysis was entered into logistic regression model for multivariable analysis. Statistical significance on the final model was declared at p-value < 0.05. Adjusted odds ratio along with 95% confidence interval was used to show strength of association. The results were presented using text, table and graphs.
Results
In this study 378 caregivers (126 cases and 252 controls) were completed the interview giving the response rate of 99.48% and 0.52% non-response rates. After multivariable logistic regression analysis, significant determinants of delay in treatment seeking for under-five pneumonia were home delivery [AOR = 2.38, 95% CI (1.37–4.14)], self-medication [AOR = 2.21, 95% CI (1.23–3.95)], non-use of community health insurance [AOR = 2.36, 95% CI (1.43–3.87)], poor knowledge of child danger sign[AOR = 2.77, 95% CI (1.39–5.5)], not heard child treatment information from media [AOR = 1.71, 95% CI (1.05–2.78)].
Conclusion
Home delivery, self-medication, non-use of community health insurance, poor knowledge of child danger sign and not heard child treatment information from media were significantly associated with delay in treatment seeking for under-five pneumonia. Health facility and Health care providers should focus on these determinants, and strengthening early diagnosis and treatment.
Keywords: Caregivers, Delay in treatment seeking, Pneumonia, Waliso Town
Introduction
Pneumonia is an acute lower respiratory tract infection that affects the lung parenchyma and impairs normal breathing. It is caused by different infectious agents, including bacteria, viruses, and fungi, and commonly presents with symptoms such as cough, fever, fast breathing, and difficulty breathing, particularly among children under five years of age [1–5]. Diagnosis is mainly based on clinical assessment and may be supported by chest radiography when necessary [4, 6].
Delayed treatment-seeking for childhood pneumonia refers to failure of caregivers to seek appropriate healthcare within 24 h after recognizing symptoms such as cough, fast breathing, or difficulty breathing [7]. Pneumonia and diarrhea remain the leading causes of death among young children worldwide. Together, these diseases account for approximately 29% of all deaths among children under five years of age, resulting in the loss of nearly two million young lives annually [8]. Each year, pneumonia alone claims the lives of about 800,000 children, making it the single largest infectious cause of child mortality equivalent to one child dying every 39 s [9]. Although the global number of clinical pneumonia episodes among young children has decreased by 22% from an estimated 178 million cases, nearly 49% of global pneumonia deaths occur in five countries: India, Nigeria, Pakistan, the Democratic Republic of the Congo, and Ethiopia [10]. n 2019, pneumonia caused 740,180 deaths among children under five, accounting for 14% of total under-five deaths and 22% of deaths among children aged 1–5 years [11]. The magnitude of delayed treatment-seeking for pneumonia was reported to be 42% in Chitwan, Nepal [12]. In Ethiopia, the magnitude ranges between 48% and 62.2%, indicating a substantial public health challenge [13, 14].
Previous studies have identified several determinants of delay, including lack of formal maternal education, absence of previous health facility visits, dissatisfaction with prior healthcare services, and perceived poor respect from healthcare professionals [15, 16]. Lack of history taking children to health facilities and lack of counseling were also the determinants of delayed treatment of childhood illness [17]. Timely recognition of the signs and symptoms by primary caregivers and subsequent care seeking for treatment can decrease many deaths of children under five due to pneumonia [18]. Taking treatment without delay can decrease the complications and death of children due to pneumonia [19]. If treatment is sought in time with an accurate diagnosis, most cases of bacterial pneumonia can be treated effectively and at a low cost with the available antibiotics, and complications and death of children due to pneumonia can be prevented [20].
Different treatment guideline was developed to treat pneumonia in children less than 5 years. The new Pneumonia kit 2020 is specifically designed to provide appropriate child-size antibiotics for treating pneumonia, targeting children under 5 years of age [8]. Ethiopia has implemented the integrated community case management to diminish mortality in childhood diseases. Despite the implementation of different guidelines for care-seeking and treatment of suspected pneumonia, from household to health facility, rates were low in Ethiopia [21].
Despite the high burden of pneumonia among children under five and the availability of treatment guidelines, important research gaps remain. Although studies in Ethiopia report delayed treatment-seeking rates of 48%–62.2%, there is limited evidence on specific determinants in Waliso Town, where local socio-cultural and health system factors may differ. Most previous studies focused mainly on caregiver-related factors, with little attention to health facility-related factors such as waiting time and service quality. Additionally, the predominance of cross-sectional designs limits strong analytical conclusions, highlighting the need for a case-control study to better identify determinants of delayed care-seeking. Therefore, this study was aimed to address this gap by using case control study design to identify determinants delay in treatment seeking of pneumonia among caregivers having under-five children in public health facility in Waliso town, South West Shoa Zone, Ethiopia.
Methods
Study area and period
The study was conducted at governmental health institutions in Waliso Town, South West Shoa Zone, Ethiopia. Waliso is located approximately 114 km south of Addis Ababa, the capital city of Ethiopia. Waliso Town has one governmental hospital, Waliso General Hospital, one non-governmental hospital known as Lukas Catholic Hospital, and two health centers: Waliso Health Center No. 1 and Waliso Health Center No. 2. According to the previous year’s annual reports, the number of pneumonia cases among children under five years of age was 3,900 and 1,800 at Waliso General Hospital, 1,200 at Waliso Health Center No. 1, and 900 at Waliso Health Center No. 2. The study was conducted from December 10, 2024, to February 10, 2025.
Study design
Institutional based unmatched case control study design was conducted.
Population
The source population consisted of all mothers or caregivers of under-five children with pneumonia who visited public health facilities in Waliso Town. The study population included mothers or caregivers of under-five children presenting with signs and symptoms of pneumonia who attended the selected public health facilities during the study period.
Eligibility criteria
Inclusion criteria
Mothers or caregivers of under-five children who presented with signs and symptoms of pneumonia at the selected public health facilities during the study period were included in the study. Cases were defined as mothers or caregivers who sought treatment for their children after 24 h of recognizing the symptoms of pneumonia, whereas controls were mothers or caregivers who sought treatment within 24 h of recognizing the symptoms.
Exclusion criteria
✔ Caregivers/mothers having under-five children who referred to study area for treatment from other areas.
✔ Caregivers/mothers who are repeat the health facility during study period.
✔ Caregivers/mothers who are unable to give information were excluded.
Sample size determination
The sample size was calculated using Epi Info version 7.2.5 by applying the double population proportion formula. Major determinants of delayed treatment-seeking for pneumonia, such as residence, self-medication, information about early treatment, and use of traditional medication, were considered [14]. After adding a 10% allowance for non-response, the final sample size became 381. To maintain a case-to-control ratio of 1:2, a total of 381 participants were included in the study, consisting of 127 cases and 254 controls.
Sampling procedure
All public health facilities in Waliso Town were included in the study. The number of study participants from each facility was allocated proportionally based on the average number of pneumonia cases among under-five children reported in the previous year adjusted for two months. The total number of under-five pneumonia cases from all facilities (N) was divided by the total sample size (n) to determine the sampling interval (K), which was 2. The first participant was selected using the lottery method. After that, systematic random sampling was used to select mothers or caregivers by interviewing every Kth participant until the required number of controls was obtained. Cases were selected consecutively, while controls were selected using systematic random sampling until the desired sample size was reached. (see Fig. 1).
Fig. 1.
Schematic presentation of sampling procedure on delay treatment seeking of pneumonia among under-five children in public health facility in Waliso town, South West Shoa Zone, 2025
Study variables
Dependent variable
Delay in treatment seeking of pneumonia.
Independent variable
Socio-demographic related factors: - age of caregivers, resident, educational status, Marital status and Occupational status.
Caregivers related factors: - Place of delivery, Knowledge of danger signs, Self-medication/traditional medication, health insurance, exposure of media, History of previous treatment and History of child death.
Health facility related factors: - Distance of health facility, Cost of transport and Cost of treatments.
Operational definition
Delayed treatment seeking for pneumonia among children under five refers to a situation in which a caregiver fails to seek appropriate healthcare services within 24 h after recognizing key symptoms of pneumonia, such as cough, fast breathing, or difficulty breathing [14].
Cases
Cases are individuals who have the outcome of interest. In this study, cases refer to caregivers of under-five children who delayed seeking treatment for pneumonia.
Controls
Controls are individuals who do not have the outcome of interest. In this study, controls refer to caregivers of under-five children who sought treatment for pneumonia without delay.
Knowledge of danger signs
Caregivers who scored greater than or equal to the cutoff point (50%) of the total knowledge score were categorized as having good knowledge of child danger signs. In contrast, caregivers who scored below the mean value were classified as having poor knowledge [22].
Data collection instrument and technique
Data Collection instrument/tools
A structured questionnaire was prepared by reviewing different literature on pneumonia outcomes [12, 14, 16, 17, 23–30]. The questionnaire consisted of three sections with a total of 22 items, including 8 items related to socio-demographic characteristics, 10 items related to caregiver factors, and 4 items related to health facility factors.
Data collection technique
Data were collected using a pre-tested structured questionnaire through face-to-face interviews. The questionnaire was initially prepared in English and then translated into Afan Oromo. The data collection was carried out by three BSc nurses who were fluent in the local language, under the supervision of one senior nurse.
Data quality control (Assurance)
To ensure the quality of the data collection tool, the questionnaire was adapted from relevant studies and pretested on 5% of the study participants at Goro Health Center. To maintain consistency, the questionnaire was first prepared in English, translated into Afan Oromo, and then back-translated into English by a language expert. The reliability of the used tools was checked with Cron bach’s alpha, which was found to be 0.63 for items of knowledge assessing.
The data collectors and supervisor were recruited from outside the staff of the study health facilities to minimize potential bias. One day of training was provided for the data collectors and supervisor on the data collection procedures, tools, objectives of the study, and ethical considerations. During the data collection period, the data collectors were closely supervised. At the end of each day, the completed questionnaires were reviewed and checked for completeness by the supervisor, and any necessary corrections were made.
Before data entry, the collected data were checked for completeness and consistency by the supervisor. Each questionnaire was properly coded and assigned a unique identification number before being entered into the data entry software. Data were entered into Epi Info to minimize entry errors and to apply the appropriate skip patterns. The data were then exported to SPSS version 25 for analysis, where outliers and missing values were checked. Multicollinearity was assessed using the Variance Inflation Factor (VIF), and the goodness of fit of the model was evaluated using the Hosmer–Lemeshow test.
Data processing and analysis
The collected data were first checked for completeness and consistency. After verification, the data were entered into Epi Info version 7.2.5 and then exported to SPSS version 25 for analysis. Both descriptive and inferential statistical analyses were performed. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to summarize the data.
Multicollinearity among independent variables was assessed using the Variance Inflation Factor (VIF) and tolerance values. The maximum VIF value was 1.26, which is well below the acceptable cutoff point of 10, and the tolerance values ranged from 0.81 to 0.952, indicating no evidence of multicollinearity. The goodness of fit of the model was evaluated using the Hosmer–Lemeshow goodness-of-fit test. The p-value for the Hosmer–Lemeshow test was 0.74, indicating that the model adequately fit the data.
Both bivariable and multivariable binary logistic regression analyses were conducted to identify factors associated with delayed treatment seeking. Variables with a p-value less than 0.25 in the bivariable analysis were included in the multivariable logistic regression model. The Adjusted Odds Ratio (AOR) with 95% Confidence Intervals (CI) was calculated, and a p-value less than 0.05 was considered statistically significant in the multivariable analysis. The findings were presented using text, tables, and charts.
Ethical consideration
The study was conducted accordance with the declaration of Helsinki. Ethical clearance was obtained from the Ethical Review Board of the College of Health Sciences and Referral Hospital, Ambo University with reference number AU/CPG/026/2017 on December 4, 2024. A permission letter was then secured from the Waliso Town Health Department, and additional permissions for data collection were obtained from all selected health facilities. Before the interview, informed consent was obtained from each study participant. Participants were informed about the purpose of the study and the significance of their participation in providing information that could help improve child health services. They were also informed that they had the right to skip any questions they did not wish to answer and to withdraw from the interview at any time. The interviews were conducted in a private area to ensure confidentiality. After obtaining consent and confirming their willingness to participate, participants were given the questionnaire and provided with instructions on how to respond to the questions.
Results
Socio-demographic characteristics of the respondents
A total of 381 participants were approached for the study, and 378 respondents (126 cases and 252 controls) completed the interview, resulting in a response rate of 99.48% and 0.52% non-response rates. The age of the respondents ranged from 17 to 45 years, with a mean age of 28.34 years (SD ± 6.45). Among the cases, 41 (32.5%) were aged 24–29 years, while 92 (36.5%) of the controls were also within the 24–29 years age group. Among the 378 study participants, 42 (33.3%) of the cases and 188 (74.6%) of the controls were urban residents. In terms of educational status, 51(40.5%) of the cases and 97 (50.5%) of the controls had secondary level education (Table 1).
Table 1.
Socio-demographic characteristics of treatment seeking of pneumonia among caregivers having children under five attending public health facilities in Waliso town, South West Shoa Zone, 2025 (n = 378)
| Variable | Variable categories | Case N (%) | Control N (%) | Total N (%) |
|---|---|---|---|---|
| Age | < 24 | 23(8.3%) | 36(14.3%) | 59(15.6%) |
| 24–29 | 41(32.5%) | 92(36.5%) | 133(35.2%) | |
| 30–35 | 29(23.0%) | 59(23.4%) | 88(23.3%) | |
| > 35 | 33(26.2%) | 65(25.8%) | 98(25.9%) | |
| Resident | Urban | 42(33.3%) | 188(74.6%) | 230(60.8%) |
| Rural | 84(66.7%) | 64(25.4%) | 148(39.2%) | |
| Marital status | Single | 4(3.2%) | 27(10.7%) | 31(8.2%) |
| Married | 109(86.5%) | 175(69.4%) | 284(75.1%) | |
| Divorced | 11(8.7%) | 48(19.0%) | 59(15.6%) | |
| Widowed | 2(1.6%) | 2(0.8%) | 4(1.1%) | |
| Educational status | No formal education | 20(15.9%) | 28(11.1%) | 48(12.7%) |
| Primary education | 46(36.5%) | 74(29.4%) | 120(31.7%) | |
| Secondary education | 51(40.5%) | 97(38.5%) | 148(39.2%) | |
| Diploma and above | 9(7.1%) | 53(21.0%) | 62(16.4%) | |
| Husband educational status | No formal education | 4(23.5%) | 13(76.5%) | 17(6.0%) |
| Primary education | 26(55.3%) | 21(44.7%) | 47(16.5%) | |
| Secondary education | 63(50.8%) | 61(49.2%) | 124(43.7%) | |
| Diploma and above | 16(16.7%) | 80(83.3%) | 96(33.8%) | |
| Occupational of caregivers /mothers Status | Housewife | 84(40.2%) | 125(59.8%) | 209(55.3%) |
| Farmer | 20(52.6%) | 18(47.4%) | 38(10.1%) | |
| Merchant | 15(17.9%) | 69(82.1%) | 84(22.2%) | |
| Employed | 7(14.9%) | 40(85.1%) | 47(12.4%) | |
| Husband occupational Status | Farmer | 60(60.0%) | 40(40.0%) | 100(35.2%) |
| Merchant | 35(33.7%) | 69(66.3%) | 104(36.6%) | |
| Employed | 14(17.5%) | 66(82.5%) | 80(28.2%) | |
| family size | Two | 36(28.6%) | 98(38.9%) | 134(35.4%) |
| 3–4 | 61(48.4%) | 92(36.5%) | 153(40.5%) | |
| above 4 | 29(23.0%) | 62(24.6%) | 91(24.1%) |
Caregivers related factors
Among the 378 respondents, 77 (61.1%) of the cases and 197 (78.2%) of the controls delivered their most recent child in a health facility, whereas 49 (38.9%) of the cases and 55 (21.8%) of the controls gave birth at home. Regarding community-based health insurance, 60 (25%) of the cases and 180 (75%) of the controls were members of the scheme. Among the total study participants, 79 (38.3%) of the cases and 127 (61.7%) of the controls were not aware of the danger signs of childhood illness (Table 2).
Table 2.
Caregivers’ related characteristics of treatment seeking of pneumonia among caregivers having under-five children attending public health facilities in Waliso town, South West Shoa Zone, 2025(n = 378)
| Variable | Variable categories | Case N (%) | Control N (%) | Total |
|---|---|---|---|---|
| Place of delivery | Health facility | 77(61.1%) | 197(78.2%) | 274(72.5%) |
| Home | 49(38.9%) | 55(21.8%) | 104(27.5%) | |
| Self-medication | Yes | 98(77.8%) | 165(65.5%) | 263(69.6%) |
| No | 28(22.2%) | 87(34.5%) | 115(30.4%) | |
| Use traditional medication | Yes | 65(51.6%) | 78(31.0%) | 143(37.8%) |
| No | 61(48.4%) | 174(69.0%) | 235(62.2%) | |
| Child treatment information from media | Yes | 99(78.6%) | 230(91.27%) | 329(87.0%) |
| No | 27(21.4%) | 22(8.73%) | 49(13.0%) | |
| Previously treatment of child? | Yes | 65(65.9%) | 166(65.9%) | 231(61.1%) |
| No | 61(48.4%) | 86(34.1%) | 147(38.9%) | |
| Child admission history | Yes | 37(29.37%) | 103(40.87%) | 140(37.0%) |
| No | 89(70.63%) | 149(59.13%) | 238(63.0%) | |
| History of child death | Yes | 11(8.73%) | 43(17.06%) | 54(14.3%) |
| No | 115(91.27%) | 209(82.94%) | 324(85.7%) | |
| Community health insurance | Yes | 60(47.62%) | 180(71.43%) | 240(63.5%) |
| No | 66(52.38%) | 72(28.57%) | 138(36.5%) | |
| Knowledge of Danger sign | Poor | 79(62.7%) | 127(50.4%) | 206(54.5%) |
| Good | 47(37.3%) | 125(49.6%) | 172(45.5%) |
Health facility related factors
The study showed that 76 (38.2%) of the cases and 123 (61.8%) of the controls required more than 60 min to reach a health facility, whereas 50 (27.9%) of the cases and 129 (72.1%) of the controls reached a health facility within 60 min or less. Among the 378 respondents, the majority of cases, 102 (81%), and 140 (55.6%) of the controls received treatment after waiting more than 30 min. However, 9 (7.1%) of the cases and 11 (4.4%) of the controls obtained treatment within 15 min (Table 3).
Table 3.
Health facility related factors of treatment seeking of pneumonia among care giver having under-five children attending public health facilities in Waliso town, South West Shoa Zone, 2025(n = 378)
| Variable | Variable categories | Case N (%) | Control N (%) | Total |
|---|---|---|---|---|
| Distance from health facility | <=60 min | 50(39.68%) | 129(51.19%) | 179(47.4%) |
| > 60 min | 76(60.32%) | 123(48.81%) | 199(52.6%) | |
| Perceived cost of treatment | Easy to pay | 3(2.4%) | 8(3.2%) | 11(2.9%) |
| Fair | 86(68.3%) | 152(60.3%) | 238(63.0%) | |
| Difficult to pay | 37(29.4%) | 92(36.5%) | 129(34.1%) | |
| Cost of transport | Easy to pay | 16(6.3%) | 0(0.0%) | 16)4.2%) |
| Fair | 102(40.5%) | 58(46.0%) | 160(42.3%) | |
| Difficult to pay | 134)53.2%) | 68(54.0%) | 202(53.4%) | |
| Waiting time to be seen by health care worker | <=15 min | 9(7.1%) | 11(4.4%) | 20(5.3%) |
| 16–30 min | 15(11.9%) | 101(40.1%) | 116(30.7%) | |
| > 30 min | 102(81%) | 140(55.6%) | 242(64.0%) |
Bivariable binary logistic regression analysis of factors associated with delay in treatment seeking of pneumonia
There were about 12 candidate variables in bivariable analysis model with p-value of < 0.25. These were: Educational status of caregivers, history of child death, Child admission history, previous treatment of child, use traditional medication, self-medication, place of delivery, use community health insurance, having knowledge of danger sign, Child treatment information from media, and distance from health facility were identified as candidate variables for multivariable logistic regression analysis (Table 4).
Table 4.
Bivariable binary logistics regression of treatment seeking of pneumonia among care giver having under-five children attending public health facilities in Waliso town, South West Shoa Zone, 2025(n = 378)
| Variables | Variables Category | Case N (%) | Control N (%) | COR 95% CI | P-value |
|---|---|---|---|---|---|
| Educational of caregivers status | No formal education | 20(15.9%) | 28(11.1%) | 4.21(1.69–10.45) | 0.002 |
| Primary education | 46(36.5%) | 74(29.4%) | 3.66(1.65–8.12) | 0.001 | |
| Secondary education | 51(40.5%) | 97(38.5%) | 3.1(1.41–6.78) | 0.005 | |
| Diploma and above | 9(7.1%) | 53(21.0%) | 1 | ||
| Place of delivery | Health facility | 77(61.1%) | 197(78.2%) | 1 | |
| Home | 49(38.9%) | 55(21.8%) | 2.28(1.43–3.63) | 0.001 | |
| Self-medication | Yes | 98(77.8%) | 165(65.5%) | 1.84(1.13–3.02) | 0.015 |
| No | 28(22.2%) | 87(34.5%) | 1 | ||
| Use traditional medication | Yes | 65(51.6%) | 78(31.0%) | 2.38(1.53–3.69) | 0.001 |
| No | 61(48.4%) | 174(69.0%) | 1 | ||
| Child treatment information from media | Yes | 99(30.1%) | 230(69.9%) | 1 | |
| No | 27(55.1%) | 22(44.9%) | 2.85(1.55–5.25) | 0.001 | |
| Previously treatment of child | Yes | 79(62.7%) | 166(65.9%) | 1 | |
| No | 47(37.3%) | 86(34.1%) | 1.81(1.17–2.80) | 0.008 | |
| Child admission history | Yes | 37(26.4%) | 103(73.6%) | 1 | |
| No | 89(37.4%) | 149(62.6%) | 1.66(1.05–2.63) | 0.03 | |
| History of child death | Yes | 11(20.4%) | 43(79.6%) | 1 | |
| No | 115(35.5%) | 209(64.5%) | 2.15(1.07–4.33) | 0.032 | |
| Community health insurance | Yes | 60(25.0%) | 180(75.0%) | 1 | |
| No | 66(47.8%) | 72(52.2%) | 2.75(1.76–4.29) | 0.001 | |
| Knowledge of Danger sign | Poor | 79(38.3%) | 127(61.7%) | 1.65(1.07–2.56) | 0.024 |
| Good | 47(27.3%) | 125(72.7%) | 1 | ||
| Distance from health facility | <=60 min | 50(27.9%) | 129(72.1%) | 1 | |
| > 60 min | 76(38.2%) | 123(61.8%) | 1.59(1.03–2.46) | 0.035 |
1 Reference COR Crude odd ratio, CI confidence interval
Multivariable binary logistic regression analysis of factors associated with delay in treatment seeking of pneumonia
After variables with a p-value < 0.25 in the bivariable analysis were entered into the multivariable logistic regression model, variables that showed a significant association with delayed treatment seeking of pneumonia were self-medication, home delivery, non-use of community health insurance, poor knowledge of danger signs, and not hearing child treatment information from the media at a p-value < 0.05.
According to the findings of this study, the odds of treatment-seeking delay for pneumonia were 2.38 times higher for in-home delivery of the current birth than for health facility delivery of the current birth [AOR = 2.38, 95% CI (1.37–4.14)]. The odds of delay in treatment seeking of pneumonia were 2.21 times more likely among respondents who used medication by themselves than respondents who did not use medication by themselves [AOR = 2.21, 95% CI (1.23–3.95)].
Similarly, caregivers who were non-users of community health insurance were 2.36 times more likely to delay in treatment seeking of pneumonia than caregivers who were users of community health insurance [AOR = 2.36, 95% CI (1.43–3.87)]. Moreover, the odds of delay in treatment seeking of pneumonia were 2.77 times higher in caregivers who did not know the child’s danger sign than in caregivers who were known about child`s danger sign [AOR = 2.77, 95% CI (1.39–5.5)]. Caregivers who did not hear child treatment information from the media were 1.7 times more likely to delay in treatment seeking of pneumonia than caregivers who heard child treatment information from the media [AOR = 1.71, 95% CI (1.05–2.78)] (Table 5).
Table 5.
Multivariable logistics regression of treatment seeking of pneumonia among care giver having under-five children attending public health facilities in Waliso town, South West Shoa Zone, 2025 (n = 378)
| Variables | Variables Category | Case N (%) |
Control N (%) |
COR95%CI | AOR 95% CI | P value |
|---|---|---|---|---|---|---|
| Place of delivery | Health facility | 77(61.1%) | 197(78.2%) | 1 | 1 | |
| Home | 49(38.9%) | 55(21.8%) | 2.28(1.43–3.63) | 2.38(1.37–4.14) * | 0.002 | |
| Self-medication | Yes | 98(77.8%) | 165(65.5%) | 1.84(1.13–3.02) | 2.21(1.23–3.95) * | 0.008 |
| No | 28(22.2%) | 87(34.5%) | 1 | 1 | ||
| Use traditional medication | Yes | 65(51.6%) | 78(31.0%) | 2.38(1.53–3.69) | 1.61(0.98–2.64) | 0.061 |
| No | 61(48.4%) | 174(69.0%) | 1 | 1 | ||
| Previously, the treatment of children | Yes | 79(62.7%) | 166(65.9%) | 1 | ||
| No | 47(37.3%) | 86(34.1%) | 1.81(1.17–2.80) | 0.639(0.39–1.05) | 0.076 | |
| Community health insurance | Yes | 31(24.6%) | 92(36.5%) | 1 | 1 | |
| No | 95(75.4%) | 160(63.5%) | 1.76(1.09–2.85) | 2.36(1.43–3.87) ** | 0.001 | |
| Child treatment information from the media | Yes | 99(30.1%) | 230(69.9%) | 1 | ||
| No | 27(55.1%) | 22(44.9%) | 2.85(1.55–5.25) | 2.77(1.39–5.5) * | 0.004 | |
| Knowledge of Danger sign | Poor | 79(38.3%) | 127(61.7%) | 1.65(1.07–2.56) | 1.71(1.05–2.78) * | 0.033 |
| Good | 47(27.3%) | 125(72.7%) | 1 | 1 |
1 Reference COR Crude odd ratio, AOR Adjusted odd ratio, CI confidence interval
*statistically significant
**strongly statistically significant
Discussion
This study examined the determinants of delay in treatment-seeking for pneumonia among caregivers of under-five children attending public health facilities in Waliso Town, South West Shoa Zone. The findings identified self-medication, home delivery, non-use of community health insurance, poor knowledge of danger signs, and lack of exposure to child treatment information from the media as significant determinants of delayed care-seeking.
According to the results of this study, caregivers who gave birth at home were 2.38 more likely to delay in treatment for pneumonia compared to caregivers who gave birth at a health facility[AOR = 2.38, 95% CI (1.37–4.14)]. This study was comparable to the study conducted in Korak Village in Chitwan [12]. The likely explanation is that home delivery is often associated with structural and socioeconomic disadvantages such as rural residence, poor access to health facilities, transportation barriers, and low household income. These same barriers that influenced the choice of home delivery may persist and continue to hinder timely healthcare-seeking for childhood illnesses. Furthermore, cultural norms and traditional beliefs that favor home delivery may also promote reliance on traditional remedies or family advice when a child becomes ill, delaying engagement with formal healthcare services.
This study identified that the odds of delay in treatment seeking of pneumonia were 2.21 more likely higher among respondents who were use medication by themselves before visiting the health care providers than respondents who were not use medication by themselves before visit the health care providers for treatment of under-five pneumonia[AOR = 2.21, 95% CI (1.23–3.95)]. This was supported by study conducted in hospitals of Bahir Dar city, North West Ethiopia [14] and in Uganda [31]. The possible justification for this might be Caregivers often obtain medications from informal sources such as drug vendors, local shops, or neighbors without proper diagnosis or prescription. This practice can create a false perception that the illness is manageable at home, thereby delaying the decision to seek professional care. The other probable justification may be self-medication may temporarily mask symptoms without addressing the underlying cause, leading caregivers to underestimate the severity of pneumonia. As symptoms initially appear to improve or remain stable, caregivers may postpone visiting healthcare facilities until the child’s condition worsens significantly. This delay increases the risk of complications and severe outcomes.
Additionally, the findings of this study showed that the delay in treatment seeking of pneumonia were 1.71 higher among caregivers who did not hear child treatment information from the media for under-five pneumonia compared to caregivers who heard child treatment information from the media for under-five pneumonia[AOR = 1.71, 95% CI (1.05–2.78)]. This was similar to the previous study conducted in sub-Saharan Africa [24]. This may be because caregivers who did not hear child treatment information from the media did not have awareness of under-five pneumonia, this delay sick children from seeking health facilities. The other probable justification maybe explained Caregivers who are exposed to media are more likely to have better awareness and understanding of pneumonia symptoms, which enables early recognition and prompt care-seeking. Media exposure also helps shape positive attitudes toward modern healthcare services by reinforcing the benefits of timely medical intervention and discouraging harmful traditional practices. On the other hand, caregivers without media exposure often lack access to accurate and timely health information. As a result, they may depend on informal sources such as family members, neighbors, or cultural beliefs, which may not provide reliable guidance. This reliance can lead to misconceptions about illness severity and inappropriate home management practices, ultimately delaying care-seeking.
Furthermore, the results of current study also showed that caregivers who were non-use of community health insurance 2.36 more likely delay in treatment seeking of under-five pneumonia than caregivers who were use of community health insurance[AOR = 2.36, 95% CI (1.43–3.87)]. This was supported by study done pneumonia in public health facilities of Nekemte city, Western Ethiopia [13]. The probable justification could be the non-users of the community health insurance might not be able afford health service price due to low monthly income that made them delay to seek healthcare. In addition, In many low-income settings, out-of-pocket healthcare payments remain a major barrier to accessing services. Caregivers without insurance may delay seeking treatment due to fear of high medical costs, including consultation fees, diagnostic tests, and medications. Community health insurance reduces this financial burden by covering or subsidizing healthcare expenses, thereby encouraging caregivers to seek care early when symptoms first appear. Insured caregivers are more likely to perceive healthcare services as affordable and accessible, which reduces hesitation and delays.
The present study revealed that the odds of delay in treatment seeking of pneumonia were 2.77 higher in caregivers who were had no knowledge of child danger sign compared to caregivers who were had knowledge of child danger sign[AOR = 2.77, 95% CI (1.39–5.5)]. This finding was similar with the study carried out in Addis Ababa, Ethiopia [32], and in Kenyatta National Hospital, Nairobi, Kenya [7]. This might be a result of the Caregivers with adequate knowledge are more likely to correctly interpret symptoms as serious and requiring immediate medical attention. This leads to prompt action and reduced delays in treatment seeking. In contrast, caregivers with poor knowledge may misinterpret these symptoms as mild or self-limiting conditions, resulting in delayed response. knowledge influences perception of severity and perceived susceptibility, which are key constructs in health behavior theories such as the Health Belief Model. Caregivers who do not perceive pneumonia as a serious illness are less likely to prioritize seeking healthcare services. The other probable reason might be due to Low knowledge is also closely associated with low educational status, limited exposure to health information, and reduced interaction with healthcare providers. These factors collectively reduce the likelihood of timely care-seeking. Therefore, the similarity across studies highlights the consistent impact of health literacy on caregiver decision-making and child health outcomes [32].
Strengths of the study
This study has several strengths that enhance its relevance and reliability. The use of a case-control study design allowed for the identification of factors associated with delay in treatment-seeking for under-five pneumonia, providing stronger evidence compared to simple cross-sectional studies. The study was conducted in Waliso Town, South West Shoa Zone, which provides context-specific insights that are directly applicable to the local population. Both caregiver-related factors, such as knowledge of danger signs, home delivery, self-medication, and media exposure, and health system-related factors, such as community health insurance utilization, were examined, offering a comprehensive understanding of determinants of delayed care-seeking. Furthermore, the findings are practically relevant, as they can inform public health interventions, policy formulation, and community-based programs aimed at reducing delays in pneumonia treatment among children under five.
Limitations of the study
The limitations of the study were recall bias may have affected the accuracy of caregiver-reported information regarding symptom recognition and timing of care-seeking. Social desirability bias is also possible, as caregivers might have over-reported timely treatment-seeking or under-reported practices like self-medication. The study included only caregivers attending public health facilities, which may not fully represent those who never seek formal care or rely on private or traditional providers. Some variables, such as knowledge and media exposure, were measured at a single point in time, limiting the ability to establish temporal causality. Certain potential confounders, including cultural beliefs, household decision-making dynamics, and caregiver workload, were not fully captured, which may influence the observed associations.
Implications of the study
The findings of this study have important implications for public health policy and practice. Targeted interventions should focus on improving caregiver knowledge of pneumonia danger signs, promoting media-based health education, and encouraging facility-based deliveries to enhance early recognition and timely treatment. Strengthening access to community health insurance and ensuring affordable, high-quality healthcare services can reduce financial barriers to care. At the community level, awareness campaigns aimed at discouraging self-medication and promoting early care-seeking are essential. Moreover, the study provides baseline evidence for future research, particularly qualitative studies exploring socio-cultural factors and caregiver perceptions. Overall, addressing these determinants can contribute to reducing complications and mortality from under-five pneumonia.
Conclusion
The findings of this study revealed that multiple interrelated factors were significantly associated with delays in seeking treatment. Specifically, self-medication practices, home delivery, non-utilization of community health insurance, poor knowledge of child danger signs, and lack of exposure to child health information through media were identified as key determinants of delayed care-seeking among caregivers of under-five children attending public health facilities in Waliso town, South West Shoa Zone.
These factors reflect a combination of behavioral, socioeconomic, and health system-related barriers. For instance, self-medication and poor knowledge of danger signs indicate gaps in caregivers’ awareness and health literacy, which can lead to misinterpretation of illness severity and postponement of professional care. Similarly, home delivery and lack of media exposure suggest missed opportunities for health education and limited engagement with formal healthcare services. Furthermore, utilization of community health insurance highlights financial constraints that may discourage timely healthcare utilization.
Recommendations
Based on the findings of this study, several recommendations can be made to reduce delays in treatment-seeking for under-five pneumonia. First, health education programs should be strengthened to improve caregivers’ knowledge of pneumonia danger signs and emphasize the importance of timely care-seeking. Community awareness campaigns through mass media, including radio, television, and social media, should be expanded to reach caregivers with limited access to health information. Second, promoting facility-based deliveries and postnatal counseling can ensure caregivers receive essential guidance on recognizing childhood illness early. Third, community health insurance schemes should be promoted and made accessible to reduce financial barriers that delay care-seeking. Health facilities should also focus on improving service quality, reducing waiting times, and enhancing caregiver satisfaction, as these factors may influence timely utilization of healthcare services. Finally, caregivers should be discouraged from self-medicating children and encouraged to seek professional care promptly. Implementing these strategies can improve early recognition and treatment of pneumonia, reduce complications, and ultimately decrease under-five mortality.
Acknowledgements
First of all, we would like to thank Ambo University College, for giving me this chance of conducting this study. In addition, we would also like to forward our deepest gratitude to our friends, and my colleague for their help and support during conducting of this study.
Abbreviations
- AOR
Adjusted Odds Ratio
- CDC
Communicable Disease Center
- SPSS
Statistical package for social science
- WHO
World Health Organization
Authors’ contributions
All the authors contributed to the proposal development, questionnaires, and data collecting process, analysis, and interpretation.Bacha Merga Chuko: Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review.Jiregna Darega: Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review.Nugusie Dibaba: Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review, & editing. Gada Edea: Investigation, Visualization, Writing – original draft, Writing, review, Formal Analysis, & editingDerara Kebata: Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review, & editing. Nebiyu Taye: Investigation, Visualization, Writing – original draft, Writing, review, Formal Analysis, & editingMulatu Ayana: Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review, & editing.
Funding
The author(s) declare that no financial support was received for the study, authorship, and/or publication of this article.
Data availability
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
An ethical clearance letter was obtained from Ethical review board of Ambo University school of Health Science. Informed consent from study participants before the interview was obtained.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.