Rural-urban disparities and factors associated with delayed care seeking for fever by mothers of under-ve children, Igabi LGA, Kaduna Nigeria.

Background Fever in under-ve children (U5) is the commonest presenting complaint in general practice and mothers’ recognition is an entry point for fever treatment including malaria. This study describes rural - urban disparity in fever prevalence, mothers’ malaria knowledge, and care seeking for fever in U5 and the associated factors. Methods A cross-sectional survey was conducted among 630 mother-child pairs [rural (300) and urban (330)] selected randomly using a multi-stage sampling from 63 villages in Igabi LGA, Kaduna State, Nigeria. Trained female data collectors administered a pre-tested structured questionnaire to collect information on mother-child demographic proles, malaria knowledge, fever episodes in birth order last child in two weeks prior to survey, and care - seeking for fever within 48 hours of onset. Care sought for fever > 48 hours of onset was dened as delayed care seeking. Malaria knowledge was categorized into good, average and poor if the nal scores is ≥ 75 th , 50 th - 74 th , and < 50 th percentiles, respectively. Frequency, proportions, and odds ratio were calculated. Statistically signicant was set at p-value < 0.05. Results The median age (interquartile range) of rural mothers was 30 (IQR, 10) years compared to 27 (IQR, 6) years in urban. Of the 70.0% (441/629) U5 children with fever, 58.5% (258/441) were in rural settlements. A third of the mothers whose child had fever sought care. Mothers in rural settlement were 2.7 (CI: 1.8 – 4.2, p < 0.01) times more likely to delay care seeking for fever, and those with no knowledge of malaria transmission were 70% less likely to seek care (OR: 0.3, CI: 0.2 – 0.7). On the other hand, poor perception of malaria as a major health problem (OR: 2.1, CI: 1.4 – 3.1), and poor knowledge of cause of malaria (OR: 1.7, CI: 1.1 – 2.5) were associated with delayed seeking for fever among urban mothers. Conclusions Disparity existed between fever prevalence in U5 children, care -seeking practices by their mothers, and

strati cation strategic information and interventions to drive impact for improve malaria elimination [4].
This underscores localized effort with focus on high-burden settings where intensi ed malaria interventions efforts are targeted at drastic reduction in malaria cases and deaths.
In Nigeria, like in other tropical countries, fever serves as a useful marker for recognition of infectious in under-ve children including malaria [6,7]. The prevalence of fever in U5 children in Kaduna State, Nigeria in 2018 was 26% [3]. Fever is a primary complaint for a third of all paediatric consultations in general practice [6,8], and an entry point for parents or mothers to seek medical attention for U5 children including malaria diagnosis and case management [7,9,10]. Though fever is not a pathognomonic sign of malaria, it usually trigger mothers to take further actions in seeking appropriate care which may be diagnosed as malaria eventually [1].
Mothers' health seeking behaviour for febrile illness in U5 children is not commensurate with the high malaria burden in Nigeria, a country with favourable climatic conditions for malaria transmission [1,2,4,11,12]. Usually, mothers being the most-at-home in Nigeria take the rst step in seeking treatment for their febrile child [13]. The knowledge and perception of the causes of the fever, and fever as indicator of illness severity may contribute to mothers' decision on how, when, and where to seek treatment advice.
The Nigeria Demographic Health Survey 2018 revealed that 29% of mothers with no education had the highest proportion of children with a fever in the past 2 weeks [3] and six out of ten mothers sought advice from private sectors like patent medicine vendors and pharmacists. Additionally, home selfmedication is a common response of mothers to fever like in other high malaria endemic countries [6,13,11]. Therefore, several factors may in uence mothers to seek care or advice for fever within 48 hours of onset in U5 children.
Some of the factors in uencing mothers' seeking advice or treatment for fever are short duration of fever [1], the season (rainy season) of the fever which coincides with high prevalence of malaria, source of treatment [14], rapid recovery from fever, rural location, availability of community-based health workers at health facilities, availability of malaria commodities in the health facilities, mother's level of education, mothers knowledge and perception of fever and malaria [10,15], lack of money for transportation and other expenses to treat the fever, and the age and sex of the child [16], perception of the family decision maker, mothers' employment status [17], household size of less than four members [12], and hospital waiting time [13,[18][19][20][21]. These factors differ from one locality to another and within sub-populations.
They in uence mothers' care seeking behaviour for fever treatment in U5 children.
Despite the several measures put in place to reduce the prevalence of fever, a quarter of U5 children in Kaduna Nigeria had fever in last 2 weeks in 2018 National Demographic Health Survey. Therefore, to develop a context speci c approach to fever treatment and drive high impact malaria elimination process in Igabi LGA Kaduna Nigeria, this study will provide information for intervention development. Therefore, it aimed to describes rural -urban disparity in fever prevalence, mothers' malaria knowledge, and associated factors with delayed care seeking for fever in U5.

Study area
Igabi Local Government Area (LGA) with headquarters at Turunku, is one of the 23 LGAs in Kaduna State, North-west geopolitical zone, Nigeria. It has a population of 557,624 and is sub-divided into ve urban districts, which are, Afaka, Birnin-yero, Kwarau, Rigachikun and Rigasa, and seven rural districts namely, Fanshanu, Gwaraji, Igabi, Kerawa, Sabo-Birnin, Turunku, and Zangon Aya. The LGA is located 650m above sea level, between latitude 10 o 47 / 0 // N and longitude 7 o 46 / 0 // E in the tropical Sahel to Sudan Savannah with annual rainfall varying from 1000 -1500 mm and highest precipitation of 72% in August. The rainy season and period of high malaria transmission is usually from June to October. The annual mean temperature is 34 o C. This can rise to 41 o C at the peak of the dry season in April and drop to as low as 12 o C in January during severe harmattan. The prevalence of malaria cases diagnosed microscopically among under-ve children in Kaduna state is 36.7% [2] This study employed a cross-sectional design.

Study design and population
This was a part of a larger study that has been published and addressed the characteristics of women of child bearing age (WCBA) associated with Long-lasting insecticidal nets (LLIN) ownership and utilization [22]. Moreover, the current analysis focused on rural -urban disparity in fever prevalence, mothers' malaria knowledge, and associated factors with delayed care seeking for fever in U5 children. Mothers and their under-ve children with at least 12 months of residence in the selected households in the community were included. Anyone with cognitive de cits, or any chronic and debilitating illness that hinders effective participation in an interview was excluded.

Sample size determination
Using the formula, n = z 2 pq/d 2 at 95% con dence interval (1.96), the percentage for children with fever for whom advice or treatment was sought in North-Western Nigeria is 63.6% [23] with a con dence limit of +/-5%, and a non-response rate of 10%. To adjust the required sample size for cluster sampling design, a correction factor of 1.5 design effect was used as a less heterogenous communities in this district was assumed. Therefore, the calculated minimum sample size was 615. However, a minimum sample size of 630 was used to accommodate the sample size for the WCBA study [22].

Sampling technique
Participants were selected using multi-stage sampling technique ( Figure 1).
The sampling technique has been described elsewhere [22]. In Stage 1, Igabi LGA was strati ed into rural and urban wards and ten wards were randomly selected. These included six rural wards -Fanshanu, Gwaraji, Igabi, Sabo-Birnin, Turunku, Zangon Aya and four urban wards -Afaka, Birnin-yero, Rigachikun, and Rigasa. For the selection of a cluster or village/settlement in stage 2, we used the household enumeration data generated by WHO/UNICEF during micro-planning for the mass long-lasting insecticidal nets (LLIN) campaign in these settlements as the sampling frame. With a sample size of 630, to improve the validity and precision of estimates and considering a wide community representation (population variance), using a probability proportional to size; 63 villages or clusters (i.e., 30 rural and 33 urban) were randomly selected with a cluster size of 10. Using the list of the households in each village/settlement generated during micro planning for mass LLIN distribution, ten households were systematically selected from each village/settlement at stage 3. One mother each was interviewed in a household. In a selected household with multiple eligible mothers of under-ve children, one was randomly selected by the ballot and recruited into the study. The last childbirth order of the eligible mothers was recruited into the study and if the last child was a set of twins, one of the twins was randomly selected by balloting.

Data collection
Data was collected by ten trained female community health extension workers and nurses who speak English and Hausa languages uently and reside within the district from September to October 2015 as described elsewhere [22]. They were supervised by ve undergraduate medical students. The data collection tool was a pretested, structured questionnaire adapted from the Malaria Indicator Survey [24 , 25] and other literature [26 , 27]. This was used to collect information on demographic pro le, mother's knowledge of malaria, history of fever onset in under-ve children and mothers' fever treatment seeking behaviour within 48 hours of fever onset. The malaria knowledge items were questions from the literature, malaria indicator surveys and demographic health surveys. The questionnaire's face and content validity, item's accuracy, relevance, and clarity has been described elsewhere [22]. The knowledge of malaria was assessed using six thematic areas including cause of malaria, mode of malaria transmission, mosquito feeding time, malaria symptoms, malaria diagnosis and malaria prevention. Participants who correctly responded that mosquito bites caused malaria, malaria transmissions to humans is through the bite of mosquito, malaria mosquito feeding time was night-time, malaria symptoms are fever and any other symptoms, and malaria preventions by using either the Long Lasting Insecticidal Nets, Indoor Residual Spray or mosquito repellent coils were given "1" and incorrect responses scored "0". The individual score was calculated by nding a percentage of total score obtained from maximum allowable score of 6 and knowledge of malaria was categorized using percentile scores.
Good knowledge of malaria, if nal score falls at 75 th percentile or more, score between 50 th to 74 th percentile as average knowledge and poor knowledge if score was < 50 th percentile.

Study variables
The outcome or dependent variables for this study was mothers' care/treatment seeking advice for fever within 48 hours of onset. Independent and explanatory variables were under-ve children and respondents' characteristics and mother's knowledge of malaria items. Fever was assumed by mothers after tactile palpation of the children's skin and felt the hotness beyond normal. However, any fever episode in under-ve children two weeks prior to the survey was taken as history of fever from which questions were asked from the mothers to know if advice or treatment was sought. Delayed care seeking for fever was de ned as inability of the mothers to seek care for U5 children withing 48 hours of fever onset [28].

Data processing and analysis
Data were entered and analysed using Epi-Info version 7 statistical software. We calculated frequency and proportions for socio-demographic characteristics, knowledge of malaria, presence of fever in underve children in last two weeks, and mothers seeking advice or treatment for fever within 48 hours of onset. We calculated median (range) for continuous descriptive variables, frequency and proportions for categorical variables. Chi squared test was used to test for association between dependent outcome and independent categorical variables; results were presented in odd ratios at 95% con dence interval (C.I). To understand the associations between explanatory variables and delayed care seeking for fever, a ruralurban strati cation analysis was done. Any associated factors with p value ≤ 0.2 were selected for upward loading into multivariable logistic regression model to identify predictors of delayed care seeking for fever by the mothers. Results of all statistical analyses were considered signi cant at p-value of <0.05.

Mothers and under ve children's characteristics
Six hundred and twenty-nine (99.8%) mothers or caregivers completed the interview of which 258 (41.1%) were employed, and 300 (47.7%) were living in rural communities. The median (interquartile range, IQR) age of mothers in the rural communities was higher 30 (IQR, 10) than the urban 27 (IQR, 6). Table 1 shows that 61.7% (185/360) of rural mothers had no education, but 45.3% (149/329) urban mothers had secondary level of education. There were signi cant differences in the rural and urban mothers' age (p = 0.001), educational level (p = 0.001) and occupations (p = 0.001). The median age (IQR) of the children was 12 months (IQR, 12). Of the 629 children 56.4% (355/629) were males, 50.6% (318/629) were aged 1 -12 months and 29.1% (183/629) aged 13 -24 months.   (Table 3). Factors associated with delayed care seeking for fever in U5 children Women who lived in rural communities were three times more likely to delay seeking care compared to their urban counterpart (OR: 3.1, 95% CI: 2.1 -4.7, p < 0.001) as shown in Table 4. Mothers with no formal education were twice more likely to delay care seeking for fever (OR: 1.8, CI: 1.2 -2.7, p = 0.003) compared to those with formal education. Those who sees malaria as not a major health problem were thrice more likely (OR: 2.6, CI: 1.2 -5.6, p = 0.01) to delay care seeking for fever in U5 and those having poor knowledge of cause of malaria were twice more likely to delay care seeking compared to mothers with good knowledge (OR: 1.7, CI: 1.1 -2.5, p = 0.01). Those who had poor knowledge of malaria mosquitoes feeding time were twice more likely to delay care seeking for fever in U5 children (OR: 1.7, CI: 1.1 -2.6, p = 0.01). Overall, the observed signi cant associations between mothers' characteristics and delayed care seeking for fever was modi ed by rural -urban community strati cation. On strati cation, among the urban mothers, the perception that malaria is not a major health problem (OR: 2.1, CI: 1.4 -3.1) and not knowing the cause of malaria (OR: 1.7, CI: 1.1 -2.5) were the signi cant factors associated with delayed care seeking for fever in U5. But in rural dwelling mothers, those who did not know the mode of malaria transmissions were 70% less likely to delay care seeking for fever (OR: 0.3, CI: 0.2 -0.7).
The predictors of mothers delaying seeking care for fever were rural location and mothers' perception that malaria is not transmitted to human through mosquito bites. Mothers in rural settlements were about thrice more likely to delay care seeking for fever in U5 children (adjusted OR: 2.7, CI: 1.8 -4.2, p < 0.01).
Finally, mothers who lacked the knowledge of malaria transmissions to humans were 60% less likely to delay seeking care for fever in U5 children (adjusted OR: 0.4, CI: 0.2 -0.8, p = 0.02).

Discussion
This study describes rural -urban disparity in fever prevalence, mothers' malaria knowledge, and factors associated with delayed care seeking for fever in U5 children at Igabi LGA, Kaduna state, Nigeria. The rural -urban disparity exists in the age of U5 children and their mothers. Also, the urban mothers were more educated, currently employed and knowledgeable on malaria than their rural counterparts. However, the rural dwelling mothers reported high prevalence of fever in U5 children, but those who sought care for fever were few.
Living in rural settlement is associated with low level of education and may in uence poor knowledge of malaria [1]. In line with previous literature, the urban mothers were exposed to formal education earlier, have access to newspapers, television, internet and social media for health information [3]. This may account for good knowledge of malaria among urban mothers than their rural counterparts. The mothers' knowledge of malaria and the recognition of fever in U5 children is vital to activate care seeking for treatment [15]. The knowledge among urban mothers does not translate to high proportion of households with mosquito nets and utilization by U5 children [22] compared with high proportion of rural mothers with poor knowledge [3].
In Nigeria, fever episode is usually common in rural communities and was corroborated in this study [2].
The educational level of mothers may in uence their decision to seek advice for care or treatment of fever in U5 children within 48 hours of onset. In this study, fever episode among U5 children in last 2 weeks occurred in three out of four. This was higher than a quarter reported in the 2018 DHS and 52.1% reported in 2015 Malaria Indicator Survey (MIS) for North West Geopolitical Zone, Nigeria [2], a survey that was done at same time as this study. Also, more fever episodes were reported in rural U5 children, like what was reported for Kaduna state in 2018 DHS where mothers in rural communities reported high proportion of U5 children with fever. Also, mothers living in urban communities sought advice for fever in U5 children earlier than rural mothers [3]. The proportion of mothers who sought advice promptly for care or treatment of fever episode within 48 hours of onset in U5 children was similar to 31.4% reported in 2015 MIS but lower to a study in Northern Nigeria that reported 61.5% [19], and 73% reported for Kaduna State in DHS 2018 [3] but higher than 28.6% reported in Ethiopia [10].
Approximately, four out of ten mothers sought care from a skilled health workers in hospital or primary health centre similar to other studies from Northern Nigeria [17,19] but higher than 28% in 2018 DHS [3].
The study like others, reported similar proportions of mothers who sought care at pharmacy shops or patent medicine vendors [15,12,16,18,29] but some mothers resorted to self-medication at home and this proportion was lower to a study from south eastern Nigeria [18] and Myanmar [16]. Good knowledge of malaria transmission and prevention has been found to be associate with care seeking from skilled health workers for fever treatment [21], self-medication at home for fever in U5 children has also been associated with mothers' level of education [1] and was the case in our study, as three out of ve mothers with formal education practiced self-medication in this study. Generally, factors like rural location of settlement, having a child who slept under LLIN a night before the survey and lack of knowledge on malaria transmission were associated with mothers delaying seeking advice or care for treatment of fever episode in under-ve children within 48 hours of onset.
Different factors dictate why mothers of U5 children will not seek advice for care or treatment of fever within 48 hours of onset. In rural settlements, mothers are likely not to seek care for fever due to their poor exposures to formal education and health information [8]. The rural -urban disparity shows that 'one-size-ts-all' approach to malaria elimination will not be effective but a context speci c intervention to drive impact for malaria elimination [4]. It shows that factors responsible to mothers delaying seeking care for fever in U5 children differs in general population compared to and between rural and urban settlements. The type of residence is an event modi er of mothers' characteristics and delay care seeking for fever. Since low education among rural dwellers accounted for high U5 fever episode and not seeking care for febrile children [1], health education, health literacy campaigns, community sensitization to improve mothers understanding of fever and appropriate use of LLIN will be of help. Whereas in urban mothers, having formal education was associated with the practice of home self-medication for fever episode in U5 children.
For Igabi LGA to achieve greater impact in malaria elimination program, different interventions for behavioural change should be implemented in rural areas with high burden of U5 fever episode. Therefore, using a strategic information to drive high impact for fever treatment in rural areas that has high burden of U5 children with fever and mothers delaying care seeking for fever in U5 children, will reduce the number of children dying of malaria [4].
The demographic characteristics in this study were similar to the 2018 Nigeria Demographic Health Survey (DHS) [3]. Further strength of this study lies in the large sample size, being a community survey with sample size well spread in urban and rural settlements of Igabi LGA. The study may not be without any limitations. It may not be generalizable to Kaduna state's populations, prone to social desirability, and information bias. The information on the last child or youngest child of the mothers were collected to minimize information bias and participants were encouraged to speak the truth, assured of their con dentiality and that no consequences if they declined to participate. Moreover, the ndings are useful for the LGA wherein this study was carried out. Despite these limitations, this study is valuable to identify areas with high burden of fever episode for intervention that will yield high impact for malaria elimination in the LGA.

Conclusions
Generally, disparity existed between fever prevalence in U5 children, care -seeking practices by their mothers, and factors associated with delayed care seeking for fever. The differences in rural-urban mothers' characteristics factors will in uence care-seeking. To rapidly scale up fever treatment for high impact on malaria elimination, the LGA and sub-national Malaria Elimination Program should employ context speci c interventions rather than 'one-size-ts-all' approach for malaria elimination strategy in Participants were informed of the nature of the survey, bene t and risks, and their right to participate and decline at any time during the interview. We obtained written informed consent from each respondent before the interview but verbally seek the permission from the household head. Participants were assured of their con dentiality and identi ed using code numbers.

Consent for publication
Not applicable.
Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests. Authors' contributions OJB conceived the study and was responsible for its design, data collection, analysis and interpretation; and writing the draft manuscript. OA contributed to conceptualization of the study and the design of its protocol, data interpretation, drafting, formatting and nal revision of the manuscript for important intellectual content. IOA contributed to data interpretation and revision of the manuscript for intellectual content. All authors read and approved the nal revised manuscript. Figure 1 Schematic representation of sampling technique