Health care seeking behavior for common childhood illnesses in Birendranagar municipality, Surkhet, Nepal: 2018.

BACKGROUND: Appropriate and prompt health care seeking by parents or caretakers can reduce morbidity and mortality among under-five year children. Although remarkable progress has been made in the reduction of under-five mortality, still the under-five mortality rate is high in Nepal. There are few studies on health care seeking behavior among caretakers in Nepal. Therefore, this study was conducted to determine the prevailing health care seeking behavior of caretakers on common childhood illness of under five year children and to identify the association of socio demographic, economic, illness related and health system related factors with health care seeking behavior in 2018.
METHODS: A community based descriptive cross-sectional study was conducted from September to November 2018. Data were collected using a pretested semi-structured interview schedule. Both descriptive and inferential statistics were used to present the data. Bivariate and multivariate logistic regression analysis was used to identify the factors associated with health care seeking behavior.
RESULTS: A total of 387 caretakers participated in the study. Of these, 84.8% sought any type of care and 15.2% did nothing. Amongst those who sought care 42.4% visited the pharmacy directly, 25.3% visited the health facility. Amongst those who visited a health facility, 37.2% of caretakers sought prompt health care. Common danger sign stated by caretakers was fever in children (92.4%). Secondary education(AOR = 0.357, 95%CI = 0.142-0.896), involvement in service as an occupation(AOR = 3.533, 95%CI = 1.096-11.384), distance to reach nearest health facility(0.957, 95%CI = 0.923-0.993) and perceived severity of illness; moderate severity (7.612, 95%CI = 2.127-27.242), severe severity (AOR = 15.563, 95%CI = 3.495-69.308) were found to be significantly associated with health care seeking behavior.
CONCLUSION: Strong policies and regulations should be formulated and implemented at Birendranagar municipality of Surkhet district to prevent direct purchase of medicines from pharmacies without any consultation. It is essential to conduct the health awareness program at community level on early recognition of danger signs and importance of consulting health facilities.

Introduction

Health or care-seeking behavior has been defined as any action undertaken by individuals who perceive themselves to have a health problem or to be ill for the purpose of finding an appropriate remedy [1].

Illnesses such as diarrhea, pneumonia, measles, malaria, and malnutrition remain major contributors to mortality among under-five children globally. Poor and delayed health care seeking has contributed to 70% of all deaths among under-five children [2].

Globally 5.5 million of under-five year children died in 2017, under-five mortality rate was 39 per thousand live births [3]. Although remarkable success has been made in survival of children since 1990, still under-five mortality rate is high in Sub-Saharan Africa, Central and Southern Asia, which accounts for more than 80 percent of under-five deaths in 2018 [4]. In Nepal, the under-five mortality rate is 39 deaths per 1,000 live births [5].

The prevalence of health care seeking is low in developing countries as compared to the developed countries. Globally around 78% of children with symptoms of Acute Respiratory Infections (ARI) were taken to the health care provider, but the coverage is only 43% in low-income countries. As many children are not taken for treatment in low-income countries disease management and surveillance has been a difficult process [6].

It has been suggested from the studies that timely health care seeking by the caretakers or family members could prevent morbidity and mortality of under-five children [7, 8]. In Nepal, there are few published studies on healthcare-seeking behavior of caretakers, and no studies have been done in the Surkhet district so far.

Therefore, this study was conducted to determine the prevailing health care seeking behavior of caretakers on common childhood illness of under five year children and to identify the association of socio demographic, economic, illness related and health system related factors with health care seeking behavior in 2018.

Materials and methods

Study design

A Community based descriptive cross-sectional study was carried at Birendranagar Municipality of Surkhet district.

Study duration and area

The study was carried from September 2018 to November 2018. Surkhet district is located about 600 Kilometer west of Kathmandu. The district’s area is 2,451 square kilometers. There are five municipalities and four rural municipalities. The study was conducted in Birendranagar municipality. The total population of Birendranagar municipality is 100,458. The under-five population is 11,787 and total households are 23, 715 [9].

There are 2 government hospitals, 3 primary health care centers, 47 health posts, 150 primary health care outreach clinics, 184 immunization clinic, 987 Female Community Health Volunteers (FCHVs), and many private hospitals and pharmacies in Surkhet district [10].

Sample size determination and sampling procedures

The sample size was calculated by taking the prevalence of healthcare-seeking behavior p = 81.4% from the study conducted in Lalitpur, Nepal [11]. Single population proportion formula; n = z2pq/d2 was used for sample size calculation [12], where z = 1.96 at 95% confidence interval, the margin of error (d) = 5%, non-response rate = 10%, As multistage random sampling method was used, to minimize the sampling error the obtained sample size was multiplied by design effect. Design effect 1.5 was used considering a previous study [13]. Hence, the total sample size taken was 387.

There were a total of sixteen wards in Birendranagar municipality. Out of 16 wards, 9 wards were selected randomly using the lottery method. A list of all caretakers having under-five year children meeting the inclusion criteria was made with the help of Female Community Health Volunteers (FCHVs) and vitamin A register of the respective wards. A systematic random sampling technique was used to obtain the required sample size (Fig 1).

Fig 1

Sampling technique.

Tool and techniques of data collection

Pretested, semi-structured interview schedule was used for the data collection. Kuppuswamy’s socioeconomic status scale modified in the context of Nepal was used to the measure socioeconomic status [14]. Questions related to health care seeking behaviors were adopted from the United Nations Children’s Fund Integrated Management of Childhood Illness (UNICEF’s IMCI) household-level questionnaire for under-five year children [15] and reviewing other relevant published studies on a similar topic. The interview schedule was translated in the Nepali language and it was pretested among 10% caretakers, those caretakers who were involved in pretesting were not included in the final study. Face to face interview technique was used.

Data processing and analysis

Data checking and editing were done manually. Coding and data entry was done in EpiData 3.1 version. Data were exported and analyzed in Statistical Package for the Social Sciences (SPSS) version 21. In descriptive statistics; frequency, percentage, mean and standard deviation were used. In inferential statistics chi-square test was used to identify the association between the outcome variable and independent variables. Variables having p-value ≤ 0.2 in bivariate analysis were entered in multivariate analysis taking the reference of various published studies [16-19]. Multicollinearity among the selected independent variables was checked through the variance inflation factor (VIF), and there were no multicollinearity issues among those variables. p-value <0.05 in multivariate analysis was used to declare that there was a statistical association.

Study variables

The conceptual framework (Fig 2) is based on the Anderson Health Care Utilization Model [14]. This model is a conceptual model aimed at demonstrating the factors that lead to the utilization of health care services.

Fig 2

Conceptual framework.

Operational definitions

Health Care Seeking Behavior was categorized into appropriate health care seeking behavior and inappropriate healthcare-seeking behavior.

Appropriate health care seeking behavior

Health care-seeking from health facilities such as hospitals, nursing homes, health centers, clinics, health posts, etc. during the illness of under five-year children was categorized as appropriate healthcare-seeking behavior.

Inappropriate health care seeking behavior

Consultation of pharmacists for medical care, self-purchase of medicine without a prescription, using home remedies, visiting traditional healers, and not seeking any care for during the illness of under-five children were classified as inappropriate healthcare-seeking behavior.

Prompt health care seeking behavior

Health care-seeking from the health facilities within 24 hours of recognition of child’s illness.

Delayed health care seeking behavior

Health care-seeking from the health facilities after 24 hours of recognition of child’s illness.

Primary caretakers

Any adult mainly female but can be male also who is responsible for the routine care of the under-five year child. Primary caretakers include mother, father, grandmother, grandfather, and aunts.

Common childhood illnesses

In this study, common childhood illnesses are Acute Respiratory Infections (ARI), diarrhea, and fever perceived by caretakers.

Acute respiratory infection

ARI is a cough accompanied by difficulty in breathing as perceived by caretakers in their under-five-year children for less than two weeks at any time within the one-month duration from the day of the interview.

History of difficulty in breathing

History of difficulty in breathing is defined as the presence of difficulty in breathing among under-five children which includes fast breathing, different breath sounds like wheezing and stridor, or chest in-drawing perceived by caretakers at any time within the one-month duration from the day of the interview.

Diarrhea

If the caretaker described that their sick children had three or more than three loose stools per day at any time within one month duration form the day of the interview.

Fever

Caretaker’s subjective evaluation fever or hot body temperature in children.

Perceived severity of illness. Perceived severity was based on the subjective evaluation of illness by caretakers on the basis of discomfort present in child and it was categorized as mild, moderate and severe.

Knowledge of the caretaker regarding danger signs of the under-five year children

Knowledge of the caretaker was measured in terms of the number of danger signs as stated by the caretakers.

Ethical approval and informed consent

Ethical approval was obtained from the Institutional Review Committee (IRC) of the Institute of Medicine, Tribhuvan University. Permission was taken from concerned authority (Public Health Service Office Surkhet and Birendranagar Municipality Office Surkhet). The objective of the study was explained to the caretakers; both verbal and written consent was obtained before the interview. Confidentiality and anonymity were maintained.

Inclusion criteria

Caretakers of under-five children residing in the Birendranagar municipality for more than six months duration and having the children with a recent episode of illness in the past one-month duration were included in the study.

Result

Socio-demographic characteristics of caretakers and under-five children

Table 1 shows the socio-demographic characteristics of the caretakers. The mean age of the caretakers was 29.35±10.03 years. Most of them (82.2%) were mothers. Regarding the occupation more than half (59.4%) of the caretakers were homemakers. About one third (31.5%) of the respondents had obtained secondary education. The mean age of the under-five children was 29.54±16.13 months.

Table 1

Socio-demographic characteristics of the caretakers and children n = 387.

Characteristics	Response	Number	Percentage
Age of the caretakers	Less than 20 years	23	5.9
	20 to 30 years	220	56.8
	More than 30 years	144	37.2
Mean ± SD (29.35±10.03 years)
Ethnicity of the caretakers	Brahmin	103	26.6
	Chhetri	99	25.6
	Aadibashi/Janajati	64	16.5
	Dalit	68	17.6
	Thakuri/Sanyashi	30	7.8
	Muslim	23	5.9
Occupation of the caretakers	Homemakers	230	59.4
	Agriculture	48	12.4
	Business	47	12.1
	Service	27	7
	Students	18	4.7
	Labor	17	4.4
Educational status of the caretakers	Illiterate	24	6.2
	Informal or just literate	59	15.2
	Primary	68	17.6
	Secondary	122	31.5
	Higher secondary	71	18.3
	Graduate post-graduate or above	43	11.1
Socio-economic status	Upper and upper middle class	135	34.9
	Middle class	129	33.3
	Lower class	123	31.8
Type of Family	Nuclear	254	65.6
	Joint	133	34.4
Relation with child	Mother	318	82.2
	Father	15	3.9
	Grandmother	36	9.3
	Aunty or other relatives	14	3.6
	Grandfather	4	1
Age of the children	Less than 12 months	69	17.8
	More than 12 months	318	82.2
Mean ± SD (29.54±16.130 months)
Sex of the children	Male	224	57.9
	Female	163	42.1
Number of children in the family	≤2	310	80.1
	3–4	70	18.1
	>4	7	1.8

Different health care seeking behavior

Table 2 shows the health care seeking behavior of caretakers. Majority (84.8%) of the caretakers sought care from different sources. The most common (42.4%) health care seeking behavior was visiting pharmacy directly without any consultation (Fig 3). Among the caretakers who visited the pharmacy, majority (89.3%) stated that fast and easy access of medicine at pharmacy.

Table 2

Distribution of respondents according to the reasons for different health care seeking behavior.

Characteristics		Number	Percentage
Care sought for childhood illness or not	Yes	328	84.8
	No	59	15.2
Reasons for consulting pharmacy directly (n = 139)**
Fast and easy access of medicine at pharmacy		109	89.3
Pharmacy was nearby		84	68.9
Don’t have to wait in line		79	64.8
It is costlier to consult a doctor		18	14.8
Illness was mild		13	10.7
Reasons for visiting health facility (n = 83) **
To avoid complications		64	78
Good treatment is available		61	74.4
Illness became severe		42	51.2
Health facility is nearby		10	12.2
Reasons for consulting traditional healer (n = 57)**
Illness was caused by an evil spirit		43	75.4
Because of repeated illness		19	33.3
Less costly		13	22.8
Traditional healer is nearby		11	19.3
Medical care was not effective		4	7
Reasons for using home remedies (n = 49)**
Due to mild illness		48	98
Less costly		22	44.9
Due to cultural beliefs		11	22.4
Home remedies do not cause any side effects/harm		9	18.4
Reasons for not seeking any care (n = 59) **
Illness was mild so waited for self- recovery		52	94.5
Treatment in health facility is costly		25	45.5
Busy at work, could not get time to go to the health facility		20	36.4
Long waiting time at health facility		8	14.5
Health facility is at far distance		7	12.7

Fig 3

Health care-seeking behaviors of caretakers.

Preferred type of health facilities by caretakers

Table 3 presents the type of health facility preferred by caretakers for the treatment of childhood illness. More than half (61.4%) of the caretakers went to private health facility followed by (38.6%) of caretakers who went to government health facility. Regarding the duration of seeking treatment more than half (62.7%) of the caretakers sought health care after 24 hours of the onset of illness while (37.2%) sought prompt health care within 24 hours of the onset of illness (Fig 4).

Table 3

Distribution of respondents by preferred type of health facilities.

Characteristics	Number	Percentage
Preferred health facility
Private health facility	51	61.4
Government health facility	32	38.6
Reasons for going to the private health facility (n = 51)**
Less waiting time	43	84.3
Good treatment	42	82.4
Private health facility is nearby	14	27.5
Health workers are available	20	39.4
Good behavior of health worker	14	27.5
Reasons going to the government health facility (n = 32) **
Good treatment	25	78.1
Less costly	21	65.6
Government health facility is nearby	14	43.8
Insurance provision	3	9.4

Multiple responses**.

Fig 4

Duration of health care seeking from the health facility.

Caretaker’s knowledge on danger signs of childhood illness

Table 4 presents the caretaker’s knowledge on danger signs. Less than three fourth (71.1%) had heard about at least one of the danger signs. The most common (92.4%) danger sign stated was fever in child.

Table 4

Distribution of caretakers according to knowledge on danger signs of childhood illness.

Characteristics	Number	Percentage
Heard about danger signs (n = 387)
Yes	275	71.1
No	112	28.9
Danger signs **
Child develops fever	254	92.4
Child becomes sicker	231	84.0
Child has difficulty in breathing	214	77.8
Child has fast breathing	200	72.7
Child is unable to drink or breastfeed	101	36.7
Child becomes unconscious	90	32.7
Child drinks poorly	87	31.6
Child vomits everything	86	31.3
Child has blood in the stool	75	27.3
Child has Convulsions	17	6.2

** Multiple responses.

Factors associated with health care seeking behavior of caretakers for their under-five children’s illness

Table 5 reveals about the factors associated with health care seeking behavior; twelve variables (ethnicity, educational status, occupation, socioeconomic status, distance to reach the nearest health facility, place of delivery, perceived severity, history of difficulty breathing, knowledge of danger signs, number of symptoms, duration of illness, number of children in a family member) that exhibited significant association with health care seeking in bivariate analysis i.e. p-value ≤ 0.2 were further analyzed in multivariate analysis using binomial logistic regression. Crude Odds Ratio (COR) was calculated by bivariate analysis in binomial logistic regression. Adjusted Odds Ratio (AOR) was calculated by multivariate analysis in binomial logistic regression. Multivariate analysis was done for the adjustment of possible confounders. Hosmer Lemeshow test, the goodness of fit of the model was assessed. The test statistic was 0.500 (>0.05) that showed that the model adequately fits the data.

Table 5

Bivariate and multivariate association of different variables with health care seeking behavior.

Characteristics		Health care Seeking Behavior		COR (95% CI)	AOR (95% CI)	P-value
		Appropriate n(%)	Inappropriate n(%)
Ethnicity	Relatively disadvantage (Ref)	10 (11.0)	81 (89.0)	1	1
	Relatively advantaged	73 (24.7)	223 (75.3)	2.6 (1.3–5.3)	1.6 (0.6–3.9)	0.309
Educational status of the caretakers	No schooling or up to primary education (Ref)	26 (17.2)	125 (82.8)	1	1
	Secondary education	15 (12.3)	107 (87.7)	0.2 (0.6–0.3)	0.35 (0.1–0.8)	0.028*
	College or University education	42 (36.8)	72 (63.2)	2.8 (1.5–4.9)	1.36 (0.6–3.9)	0.453
Occupation of caretaker	Other than service (Ref)	63 (18.4)	279 (81.6)	1	1
	Service	12 (44.4)	15 (55.6)	3.5 (1.5–7.9)	3.5 (1.0–11.3)	0.035*
Socio economic status	Lower class(Ref)	17 (13.8)	106 (86.2)	1	1
	Middle class	25 (19.4)	104 (80.6)	1.4 (0.7–2.9)	1.5 (0.6–3.8)	0.308
	Upper class	41 (30.4)	94 (69.6)	2.7 (1.4–5.1)	1.1 (0.4–2.7)	0.776
Distance to reach nearest health facility(n = 387)				0.9 (0.9–0.9)	0.9 (0.9–0.9)	0.020*
Place of delivery	Home(Ref)	6 (8.8)	62 (91.2)	1	1
	Health facility	77 (24.1)	242 (75.9)	3.2(1.3–7.8)	2.7 (0.8–9.2)	0.092
Perceived severity	Mild (Ref)	5 (5.7)	82 (94.3)	1	1
	Moderate	44(22.6)	151(77.4)	4.7 (1.8–12.5)	7.6 (2.1–27.2)	0.002*
	Severe	34(32.4)	71(67.6)	7.8 (2.9–21.1)	15.5 (3.4–69.3)	<0.001**
History of difficulty breathing	No (Ref)	45 (18.1)	203 (81.9)	1	1
	Yes	38 (27.3)	101 (72.7)	1.6 (1.0–2.7)	1.7 (0.6–4.6)	0.235
Knowledge on danger signs(n = 275)				1.1(1.0–1.3)	0.9 (0.8–1.1)	0.903
Number of symptoms	One (Ref)	22 (22.7)	75 (77.3)	1	1
	Two	13 (14.3)	78 (85.7)	0.5 (0.2–1.2)	0.4 (0.1–1.2)	0.11
	≥Three	48 (24.1)	151(75.9)	1.0 (0.6–1.9)	0.4 (0.1–1.2)	0.1
Duration of illness	≤ 3 days (Ref)	11 (12.8)	75 (87.2)	1	1
	4 to 7 days	29 (23.8)	93 (76.2)	2.1 (0.9–4.5)	1.28 (0.4–3.5)	0.626
	>7days	43 (24.0)	136 (76.0)	2.1 (1.0–4.4)	0.4 (0.08–2.6)	0.402
Number of children	>2 children (Ref)	72 (23.2)	238 (76.8)	1	1
	Up to 2 children	11(14.3)	66 (85.7)	1.8 (0.9–3.6)	1.6 (0.5–4.7)	0.359

*p value <0.05,

**p value <0.001,

AOR = Adjusted Odds Ratio, COR = Crude Odds Ratio, Ref = Reference Category, n = number of samples.

In multivariate regression analysis, caretakers with secondary education were less likely (AOR = 0.3, 95% CI = 0.1–0.8) to seek appropriate healthcare-seeking behavior than those who had no schooling or had gained primary education, and higher educational status. Those caretakers who were involved in service as occupation were three times (AOR = 3.5, 95% CI = 1.0–11.3) more likely to seek appropriate health-seeking than those who were involved in other occupations. Similarly, with the increasing distance to reach the nearest health facility, caretakers were less likely to seek appropriate health seeking behavior (AOR = 0.9, 95% CI = 0.9–0.9). Regarding perceived severity those caretakers who perceived that their children had moderate severity of illness were around eight times (AOR = 7.6, 95% CI = 2.1–27.2) more likely to seek appropriate health-seeking behavior, similarly, those caretakers who perceived that their children had a severe illness were fifteen times (AOR = 15.5, 95% CI = 3.4–69.3) more likely to seek appropriate health care than those who perceived illness as mild.

Discussion

This study revealed that only one quarter (25.3%) of the caretakers with ill under-five children sought health care from the health facility as the first source of care. This finding is consistent with the study findings from Rural Nigeria, Pokhara, North West Ethiopia [20-22]. This might be due to the pluralistic health system in the country where mothers or caretakers seek health care from various sources and do not visit the health facility until the illness become severe.

The current study showed that among the action taken during childhood illness the most common action (42.4%) was visiting pharmacy at first rather than going to a health facility. Different studies have shown that pharmacy is the most common source of health care seeking for childhood illness [5, 21, 23]. This might be due to the easy access to medicine form the pharmacy and caretakers do not have to pay a consultation fee for doctors. In the context of the Birendranagar municipality, there are abundant pharmacies as compared to the health facility, pharmacies are present in each ward, so caretakers prefer to buy medicine directly from the pharmacy rather that going to the health facility.

In this study, the most common reason for not seeking any care for their children’s illness was illness being mild and it would recover itself. This finding is consistent with the study findings from Yemen and North West Ethiopia, where reasons for not seeking medical care were illness being mild and illness would recover itself [22, 24].

This study has revealed that caretakers preferred private health facilities over government health facilities for treating the illness under-five children, Similar findings were shown by the studies from Nepal and Pakistan [5, 25]. Reasons for preferring private health facilities might be due to the availability of prompt care and caretaker’s perception of good quality of health care at private health facilities.

The result of multivariate analysis showed that with the increase in distance from the health facilities caretakers were less likely to seek appropriate health care (AOR = 0.957, 95% CI, 0.923–0.993). This finding is consistent with the study findings from Ethiopia and a systematic review where caregivers located near to health care facilities were more likely to visit the health facility than those who lived far [26, 27]. The reason might be with the increase in distance from the health facility the transportation cost increases, it is difficult for caretakers to travel long distance with the child, so caretakers prefer to take the ill child to the nearby pharmacist or they try home remedies or they go to the nearby traditional healers. Most of the caretakers are mothers and they have many competing household duties to do at home so they do not take their child to a health facility unless illness becomes severe.

The current study revealed that caretakers who had gained secondary education were less likely to seek appropriate health care (AOR = 0.357, 95% CI 0.142–0.896) than those who were illiterate or had gained education up to the primary level. This might be due to the reason that caretakers with no education or primary education might become more conscious about the child’s illness and they might not have knowledge about self- medication, so they took their child to health facility directly but among caretakers, with secondary education, they have little knowledge about medications, so they try self-medication for their child either by buying medicine from the pharmacy directly or might use different home remedies. This finding is similar to the study finding from rural India where parents with high school education and graduates were more likely to practice self -medication than illiterate parents [28]. Likewise, a study done in Kerela, India showed that mothers with higher educations were less likely to seek health care [29].

It was found that caretakers who perceived illness as severe were more likely to seek appropriate health care than those who perceived illness as mild. The possible reason might be when caretakers perceived their children have a severe illness they are more likely to seek care from health facilities to avoid further complications.

The current study showed a significant association between occupation and appropriate healthcare-seeking. Those caretakers who are involved in service as occupation were about four times more likely to seek appropriate health care (AOR = 3.533, 95% CI 1.096–11.384). This may be due to the reason that those caretakers who are involved in service are economically independent as well as have a higher education level. If their child gets ill they know that child should be taken immediately to the health facility and they can also afford to treat their child at the health facility.

Limitation of the study

This study has some limitations; the answers provided by caretakers were based on the perception of caretakers about the illness of their children not based on exact medical diagnosis. Illnesses of only one month’s duration were included to minimize the chances of recall bias.

Conclusion

This study concluded that only one-quarter of the caretakers seek care from health facilities during their children’s illness. Among healthcare-seeking behavior, the most common source was visiting the pharmacy directly at first rather than going to the health facility. Six out of ten health workers preferred private health facilities over government health facilities. Only four out of ten caretakers sought prompt health care. Caretakers had low awareness of danger signs of childhood illness. Four factors such as distance to reach the nearest health facility, education of the caretakers, perceived severity of the illness, and occupation of the caretakers were found significantly associated with healthcare-seeking behavior. Strong policy and regulations should be formulated and implemented at Birendranagar Municipality of Surkhet district to prevent direct purchase of medicines from pharmacies without any consultation. It is essential to conduct the health awareness program at community level on early recognition of danger signs and importance of consulting health facilities.

Data collection tool in English.

(DOCX)

Click here for additional data file.

Data collection tool in Nepali.

(DOCX)

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Data set underlying the findings of this study in SPSS.

(SAV)

Click here for additional data file.

3 Sep 2020

PONE-D-20-18110

Factors associated with health care seeking behavior on perceived illness of under five year children among caretakers in Birendranagar municipality, Surkhet, Nepal

PLOS ONE

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Additional Editor Comments:

1.Table 6, you should list the number of samples for each variable category.

2.Table 6, the definition of Ethnicity is not explained.

3.Table 6, is the secondary education includes higher secondary within the education level?

4.Why does Table 6 list the service industry separately? The service industry only accounts for 7%.

5.Table 6, i don't see the definition of socioeconomic status classification.

6.Does the distance between Table 6 and health care facilities refer to the geographical distance or the travel time as in Table 2?

7.Table 6, about the history of difficult breathing, the definition of difficulty?

8.What is the operational definition of knowledge for dangerous signals in Table 6?

9.From Table 2 we know that the reasons for choosing public and private medical institutions are different, and the regression analysis of seeking medical behaviors can be considered as a stratified analysis.

10.It is recommended that the coding method of the dependent variable be presented below Table 6 for explanation.

11. Is it confirmed that there are no multicollinearity issues.

12.The quality of logistic regression model and the result about Hosmer-Lemeshow Test?(less...)

Generally, it is a useful paper since it addresses one of the major problems in developing countries, the relatively high death-rate of new-borns and small children. Unfortunately, however, there are some shortcomings which should be addressed before accepting this paper for publication.

The authors refer to several studies in the Discussion chapter, sometimes to one or two, other times to other one or two, etc, but no general overview of these studies has been given. Probably the whole paper could be made shorter if a summary (maybe even in a table format) would be presented in the Introduction, and the major points would be stated. Later, then, they only have tp refer to this section.

Methods are poorly described, especially regarding the interviews. No detailed information is given about the questions of the interviews. At least some typical examples and variations should be presented (maybe as an Appendix). The interview method is typically a crucial information since it can manipulate the interviewees and can lead to false interpretation. It isn’t clear, too, what method for coding had been used.

It seems unusual to use 0.2 p-value for statistical analysis; at least some explanation should be given.

Discussion is too long, generally because results are repeated several times in this section. Generally, Discussion is an overview of the results obtained is a short and compact format, to give the reader an impression about the meaning of the research. The many references to other studies make it even more complicated (see above).

A technical note: No explanation is given on the first mention for abbreviation ARI (Page 4), that of FCHV (Page 5), IMCI (Page 6). etc. Although there is a list of abbreviations at the end of the manuscript, the reader does not find it while reading the text. Either the table should be placed onto the beginning of the paper, or abbreviations should be explained when first mentioned.

Overall opinion: it is an important topic, but the manuscript requires general improvement (major revision) before accepting.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Generally, it is a useful paper since it addresses one of the major problems in developing countries, the relatively high death-rate of new-borns and small children. Unfortunately, however, there are some shortcomings which should be addressed before accepting this paper for publication.

The authors refer to several studies in the Discussion chapter, sometimes to one or two, other times to other one or two, etc, but no general overview of these studies has been given. Probably the whole paper could be made shorter if a summary (maybe even in a table format) would be presented in the Introduction, and the major points would be stated. Later, then, they only have tp refer to this section.

Methods are poorly described, especially regarding the interviews. No detailed information is given about the questions of the interviews. At least some typical examples and variations should be presented (maybe as an Appendix). The interview method is typically a crucial information since it can manipulate the interviewees and can lead to false interpretation. It isn’t clear, too, what method for coding had been used.

It seems unusual to use 0.2 p-value for statistical analysis; at least some explanation should be given.

Discussion is too long, generally because results are repeated several times in this section. Generally, Discussion is an overview of the results obtained is a short and compact format, to give the reader an impression about the meaning of the research. The many references to other studies make it even more complicated (see above).

A technical note: No explanation is given on the first mention for abbreviation ARI (Page 4), that of FCHV (Page 5), IMCI (Page 6). etc. Although there is a list of abbreviations at the end of the manuscript, the reader does not find it while reading the text. Either the table should be placed onto the beginning of the paper, or abbreviations should be explained when first mentioned.

Overall opinion: it is an important topic, but the manuscript requires general improvement (major revision) before accepting.

Reviewer #2: 1.Table 6, you should list the number of samples for each variable category.

2.Table 6, the definition of Ethnicity is not explained.

3.Table 6, is the secondary education includes higher secondary within the education level?

4.Why does Table 6 list the service industry separately? The service industry only accounts for 7%.

5.Table 6, i don't see the definition of socioeconomic status classification.

6.Does the distance between Table 6 and health care facilities refer to the geographical distance or the travel time as in Table 2?

7.Table 6, about the history of difficult breathing, the definition of difficulty?

8.What is the operational definition of knowledge for dangerous signals in Table 6?

9.From Table 2 we know that the reasons for choosing public and private medical institutions are different, and the regression analysis of seeking medical behaviors can be considered as a stratified analysis.

10.It is recommended that the coding method of the dependent variable be presented below Table 6 for explanation.

11. Is it confirmed that there are no multicollinearity issues.

12.The quality of logistic regression model and the result about Hosmer-Lemeshow Test?

**********

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Reviewer #1: No

Reviewer #2: No

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5 Oct 2020

Response to the reviewer and editor

Date: October 5, 2020

To the Editor,

PLOS ONE Journal

Greetings! Hope you are fine and doing well. First of all, I would like to thank both the editor and reviewers for the extensive review of our manuscript and providing us opportunities to revise it. I have tried to incorporate all the feedback provided to us. For the revision of this manuscript, I took the support of my colleagues Dr. Sushil Pokhrel and Dr. Ganesh Tiwari. I checked language, spellings, and grammar using software/app for made for checking grammar. I have manually checked each sentence of this manuscript. I have mentioned below a table that explains my response in each comment of the reviewers and editor. Now, I am submitting the revised version of the manuscript as well as the original version with track changes. I am also submitting the supporting information such as tools of data collection in English as well as Nepali language and SPSS data set. Thank you very much for your time and consideration.

Best regards!

Ganga Tiwari

SN. Comments by editor and reviewer Response

Editor Comments

1 Table 6, you should list the number of samples for each variable category

- Yes, I have listed the number of samples for each variable

2 Table 6, the definition of Ethnicity is not explained

- I have provided an operational definition of ethnicity.

3 Table 6, is that secondary education includes higher secondary within the education level?

- No the secondary education includes lower secondary education (6th standard to 10th standard) in our study.

Higher secondary is considered a college education in our study.

4 Why does Table 6 list the service industry separately? The service industry only accounts for 7%.

- I have checked the association of healthcare-seeking behavior with all the occupations categorizing into two group like home makers and non-homemakers/ business and non-business/agriculture and non-agriculture and service and non-service, I did not found any association among other categories but I found association with service and non -service category, so I have listed service and non-service category in table 6.

5 In table 6, I don't see the definition of socioeconomic status classification.

- Now, I have mentioned the definition of socioeconomic class in the operational definition.

6 Does the distance between Table 6 and health care facilities refer to the geographical distance or the travel time as in Table 2?

-Yes, the distance mentioned in table 6 refers to the geographical distance which is measured in travel time as in table 2. But in Bivariate and multivariate analysis I have not categorized distance into below 30 min and above 30 min, as the distance is a continuous variable I directly check the association of distance and healthcare-seeking behavior. It was measured in travel time to reach the nearest health facility in minutes.

7. Table 6, about the history of difficult breathing, the definition of difficulty?

- Now, I have mentioned about the definition of difficulty in breathing in the operational definition.

8. What is the operational definition of knowledge for dangerous signals in Table 6?

-Now, I have mentioned the definition of knowledge of danger signs in table 6 at the operational definition section.

9 From, Table 2 we know that the reasons for choosing public and private medical institutions are different, and the regression analysis of seeking medical behaviors can be considered as homemakers analysis. Yes, the regression analysis of seeking medical behavior can be considered as a stratified analysis.

10 It is recommended that the coding method of the dependent variable be presented below Table 6 for an explanation.

- Now, I have mentioned in the data analysis section under methodology.

11 Is it confirmed that there are no multicollinearity issues?

- Yes, I have calculated the Variance Inflation Factor (VIF) among the independent variables selected in the multivariate logistic analysis model. VIF value was less than 2 for every variable checked. So it is confirmed that there is no issue of multicollinearity.

12 The quality of the logistic regression model and the result of the Hosmer-Lemeshow Test? (less...)

-Hosmer Lemeshow test, the goodness of fit of the model was assessed. The test statistic was 0.500 (>0.05) that showed that the model adequately fits the data.

The authors refer to several studies in the Discussion chapter, sometimes to one or two, other times to other one or two, etc, but no general overview of these studies has been given. Probably the whole paper could be made shorter if a summary (maybe even in a table format) would be presented in the Introduction, and the major points would be stated. Later, then, they only have to refer to this section.

- Now, I have tried to make the discussion section shorter by reducing the repeated contents of result and mentioned only major issues.

Methods are poorly described, especially regarding the interviews. No detailed information is given about the questions of the interviews. At least some typical examples and variations should be presented (maybe as an Appendix). The interview method is typically a crucial information since it can manipulate the interviewees and can lead to false interpretation. It isn’t clear, too, what method for coding had been used.

- Now, I have explained the interview technique in the methodology part. Regarding the coding of the dependent variable, I have now explained in the operational definition.

A technical note: No explanation is given on the first mention for abbreviation ARI (Page 4), that of FCHV (Page 5), IMCI (Page 6) etc. Although there is a list of abbreviations at the end of the manuscript, the reader does not find it while reading the text. Either the table should be placed onto the beginning of the paper, or abbreviations should be explained when first mentioned.

Overall opinion: It is an important topic, but the manuscript requires general improvement (major revision) before accepting.

- Now I have explained abbreviations when used at first and then I have kept list of abbreviations at the last section of manuscript.

Journal requirement

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming

- Now I have revised my manuscript using PLOS ONE’s style requirement, and I have named file name accordingly.

We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service.

- Yes, I have thoroughly copyedited my manuscript for language, spelling, and grammar through grammar checking websites/apps as well as with the help of my colleagues.

It seems unusual to use 0.2 p-values for statistical analysis; at least some explanation should be given.

Discussion is too long, generally because results are repeated several times in this section. Generally, Discussion is an overview of the results obtained is a short and compact format, to give the reader an impression about the meaning of the research. The many references to other studies make it even more complicated (see above).

- It has been shown in a study that use of p-value < 0.05 is too stringent and often excludes important variables from the logistic regression model, so choosing a p-value ranging from 0.15 to 0.20 is highly recommended, various published studies have used p-value 0.2 for selecting the variables for multivariate logistic regression. Now I have explained this in the manuscript also.

Now I have tried to make the discussion section shorter by reducing the repeated contents of result and mentioned only major issues

Submitted filename: Response to Reviewer.docx

Click here for additional data file.

2 Feb 2021

PONE-D-20-18110R1

Factors associated with health care seeking behavior on the perceived illness of under five year children among caretakers in Birendranagar municipality, Surkhet, Nepal

PLOS ONE

Dear Dr. Tiwari,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

Thank you for addressing all the comments on the previous version. The manuscript is is a good shape at the moment. We only have some minor comments to further improve the language and readability of the manuscript. Hope to receive the revised manuscript soon.

==============================

Please submit your revised manuscript by Mar 19 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Shyam Sundar Budhathoki, MBBS, MD, MPH

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: Title: needs to be modified, can be made short

Abstract: Objective needs to be more specific. Conclusion needs language editing, can be made short. Last statement not a part of study objective.

Keywords: can be written as per MeSH terms

Introduction: needs language editing ; can be made short.

Objectives: need to be more specific

Methods: section needs to be rewritten. It is very lengthy, can be made short with only relevant details. Sample size and technique can be explained by a flowchart; will make it concise and reflect better understanding. “FCHVs” needs to be spelt out for the first time in text, it can later be used as an abbreviation. Was Kuppuswami scale modified Nepali version validated, before using in study. “Perceived Illness” used in study can be elaborated in operational definition section. Inclusion criteria mentions about only the treatment seeking period of last one month, which is a major limitation. Childhood/under-five manifestations may not always be present, a longer duration would be better like 3 months. Sentence construction not proper, grammatical errors need to be corrected. Pretesting of study tool mentioned, but whether the same sample was included in the sample size or not, is not mentioned.

Results: require language editing.

“Perceived Illness” needs to be explained in methodology. Similarly, “Perceived Severity” mentioned not explained in text. Too many[Table 1 to 5] tables. Can be combined with statistical analysis part of bivariable analysis. Multivariable analysis[Table 6] is fine.

Discussion: is very elaborate; can be shortened in length and only relevant findings highlighted.

Limitations: not mentioned

References: Some old references may be removed. Recent studies within last 5 years can be cited.

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

22 Mar 2021

Reviewer #3: Title: needs to be modified, can be made short

-The title has been modified and made short

Abstract: Objective needs to be more specific. Conclusion needs language editing, can be made short. Last statement not a part of study objective

-Now, objectives are written more specifically, conclusion section has been edited.

Keywords: can be written as per MeSH terms

-Now, Key words are written as per MeSH terms

Objectives: need to be more specific

-Now, the objectives are written more specifically.

Methods: section needs to be rewritten. It is very lengthy, can be made short with only relevant details. Sample size and technique can be explained by a flowchart; will make it concise and reflect better understanding. “FCHVs” needs to be spelt out for the first time in text, it can later be used as an abbreviation. Was Kuppuswami scale modified Nepali version validated, before using in study. “Perceived Illness” used in study can be elaborated in operational definition section. Inclusion criteria mentions about only the treatment seeking period of last one month, which is a major limitation. Childhood/under-five manifestations may not always be present, a longer duration would be better like 3 months

-We have rewritten methodology section. We have tried to make it short. Sampling technique is now explained by a flowchart. FCHVs are now written in full word when it is first used.

Kuppuswamy scale modified in context of Nepal was was used; this version was already validated in context of Nepal and used by various published studies.

Perceived illness is now defined on the operational definition section.

Illness period of only one month duration was taken to avoid recall bias among the caretakers.

Results: require language editing.

“Perceived Illness” needs to be explained in methodology. Similarly, “Perceived Severity” mentioned not explained in text. Too many[Table 1 to 5] tables. Can be combined with statistical analysis part of bivariable analysis. Multivariable analysis[Table 6] is fine

-Perceived illness and severity has been defined in the operational definition section. Some tables have been removed, language editing has been done in result section.

Discussion: is very elaborate; can be shortened in length and only relevant findings highlighted ----

-Discussion section has been made short.

Limitations: not mentioned

-Now, limitation has been mentioned.

References: Some old references may be removed. Recent studies within last 5 years can be cited.

-Some old references have been removed.

Submitted filename: Response to reviewers.docx

Click here for additional data file.

9 Jun 2021

PONE-D-20-18110R2

Health care seeking behavior for common childhood illnesses in Birendranagar municipality, Surkhet, Nepal

PLOS ONE

Dear Dr. Tiwari,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jul 24 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see:  http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at  https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Shyam Sundar Budhathoki, MBBS, MD, MPH

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #4: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #4: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #4: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #4: Health care seeking behavior for common childhood illnesses in Birendranagar municipality, Surkhet, Nepal

Reviewer: Wingston Ng’ambi (Lecturer and Research Scientist), College of Medicine- Kamuzu University of Health Sciences (Formerly University of Malawi), Lilongwe, Malawi; & Institute of Global Health, University of Geneva, Geneva, Switzerland

This is a nice paper touching on an important area.

1. The title should be changed to “Factors associated with healthcare seeking behavior for common illnesses amongst under-five children in Surkhet district, Nepal: 2018“

2. The manuscript needs to be numbered in order to reference to line numbers. This makes review easier.

Abstract

Introduction of abstract

3. “There are few studies on health care seeking behavior among caretakers in Nepal, so the objective of this study was to itsassess the healthcare-seeking behavior of the caretakers in Birendranagar municipality of Surkhet district. So, this study aims to identify prevailing health care seeking behavior of caretakers on perceived illness of under five year children and to identify the association of socio demographic, economic, illness related and health system related factors with health care seeking behavior.” Should be changed to “There are few studies on healthcare seeking behavior among caretakers in Nepal. Therefore, we conducted this study to determine the level of healthcare seeking behavior of caretakers on perceived illness and to identify the factors associated with health care seeking behavior of the caretakers of under five-year children from Surkhet district in Nepal in 2018.”

Methods section of abstract

4. Add level of P-value for statistical significance

5. How the logistic regression models were built (optional depending on word count)

Results

6. Change “Regarding healthcare-seeking behavior of caretakers for their children’s illnesses, the most common source of care-seeking was visiting pharmacy directly at first (42.4 %), only one quarter (25.3 %) of the caretakers visited health facilities, among those who visited health facilities, only (37.2 %) of caretakers sought prompt health care.” to “Of these, 42.4% visited the pharmacy directly, 25.3% visited the health facilities and XXXX did nothing. Amongst those who visited a health facility, 37.2% of caretakers sought prompt health care.”

Conclusion

7. Rather than just repeat the results consider using statements like (“There is a need to understand and address individual and socio-economic barriers to health seeking to increase access and use of health care and fast-track progress towards Universal Health Coverage amongst children from Surkhet district in Nepal.” This is what would be an appropriate conclusion that answers the question: How does this study relate to the SDGs and universal health coverage as well as Nepal National Health Strategy?

Main body of the paper

8. Include a running title of the paper

Introduction

9. Change the objectives as stipulated in the abstract

Methods

10. p-value should be changed to P-value

11. The authors should make it clear how they arrived at the final model. Did they use log likelihood ratio methods or some other methods? They also need to be clear on what multivariate analysis that they are conducting.

12. Under a subsection “Appropriate health care seeking behavior” several studies include obtaining care from pharmacies as appropriate health care seeking behaviour (HSB), how come you are doing this differently?

13. Can you refer to “Ng'ambi W, Mangal T, Phillips A, Colbourn T, Mfutso-Bengo J, Revill P, Hallett TB. Factors associated with healthcare seeking behaviour for children in Malawi: 2016. Trop Med Int Health. 2020 Dec;25(12):1486-1495. doi: 10.1111/tmi.13499. Epub 2020 Oct 19. PMID: 32981174.” for some operational definition of HSB.

Results

14. Format the tables for characteristics to look like this.

Patient characteristics n (%)

Total 255229 (100.0)

Gender

Male 122610 (48.0)

Female 125275 (49.1)

Missing 7344 (2.9)

Location

Rural 168258 (65.9)

Urban 86971 (34.1)

Age at Sample draw (in months)

0-1 145622 (57.1)

2-5 74707 (29.3)

6-11 21307 (8.4)

12-17 3337 (1.3)

18-24 1902 (0.8)

Missing 8354 (3.3)

Region

Northern 22897 (9.0)

Central 72,633 (28.5)

Southern 159699 (62.6)

Year Sample drawn

2013 16308 (6.4)

2014 25858 (10.1)

2015 41271 (16.2)

2016 41178 (16.1)

2017 42252 (16.6)

2018 43370 (17.0)

2019 36372 (14.3)

2020* 7741 (3.0)

Missing 879 (0.3)

15. In all tables do not combine the mean or SD if the headings are number and percentage

16. All tables should not have lines crossing them

17. Include the illnesses (like fever, diarrheas) as appriori variables in the final multivariate model as these form key part of your analysis. Also include age and sex of the child as appriori variables.

18. We are not sure of the P-value for Table 5. Is it for crude or adjusted estimates? I would format the table to look like:-

Characteristics (n=26386) Bivariate analysis Multivariate analysis

OR (95%CI) P-value OR (95%CI) P-value

Age group

15-19 1.00 1.00

20-24 1.10 (1.00-1.21) 0.06 1.26 (1.13-1.41) <0.001

25-29 1.07 (0.96-1.18) 0.22 1.42 (1.24-1.62) <0.001

30-34 1.06 (0.95-1.18) 0.33 1.48 (1.27-1.72) <0.001

35-39 1.07 (0.95-1.21) 0.27 1.61 (1.36-1.92) <0.001

40-44 0.91 (0.78-1.07) 0.25 1.47 (1.19-1.81) <0.001

45-49 1.02 (0.80-1.30) 0.88 1.77 (1.33-2.34) <0.001

Year

2004/5 1.00 1.00

2010 1.23 (1.14-1.32) <0.001 1.21 (1.12-1.31) <0.001

2015/16 2.19 (2.03-2.37) <0.001 2.12 (1.97-2.29) <0.001

Region

North 1.00

Centre 1.03 (0.94-1.12) 0.55

South 0.96 (0.88-1.05) 0.40

Number of previous children ever born

1 1.00 1.00

2-3 0.79 (0.74-0.85) <0.001 0.70 (0.64-0.76) <0.001

4-5 0.74 (0.68-0.80) <0.001 0.62 (0.55-0.70) <0.001

6+ 0.69 (0.63-0.75) <0.001 0.59 (0.51-0.69) <0.001

Education level

None 1.00 1.00

Primary 1.22 (1.13-1.32) <0.001 1.09 (1.00-1.18) 0.05

Secondary 1.69 (1.54-1.86) <0.000 1.24 (1.11-1.39) <0.001

Tertiary 4.36 (3.42-5.57) <0.001 2.35 (1.80-3.06) <0.001

Wealth index quintile

Poorest 1.00 1.00

Poorer 1.07 (0.99-1.16) 0.10 1.07 (0.99-1.17) 0.09

Middle 1.09 (1.00-1.18) 0.05 1.10 (1.01-1.20) 0.024

Richer 1.17 (1.07-1.28) <0.001 1.15 (1.05-1.26) 0.002

Richest 1.47 (1.35-1.60) <0.001 1.23 (1.11-1.36) <0.001

Residence

Urban 1.00

Rural 0.78 (0.72-0.84) <0.001

Sources of antenatal care knowledge

Frequency of listening to radio

Less than once a week 1.00

At least once a week 1.00 (0.95-1.05) 0.97

Frequency of watching television

Less than once a week 1.00 1.00

At least once a week 1.44 (1.31-1.58) <0.001 1.13 (1.02-1.26) 0.025

Barriers to access antenatal care

Permission to visit health services

No problem 1.00

Big problem 1.10 (1.02-1.19) 0.01

Money to pay for health services

No problem 1.00

Big problem 0.88 (0.83-0.92) <0.001

Distance to health facilities

No problem 1.00

Big problem 0.93 (0.88-0.98) 0.005

Presence of companion

No problem 1.00

Big problem 0.98 (0.92-1.04) 0.50

No drugs at health facility

No problem 1.00

Big problem 1.28 (1.21-1.35) <0.001

No female provider

No problem 1.00

Big problem 1.01 (0.95-1.09) 0.64

Marital status

Never married 1.00 1.00

Married 1.20 (1.02-1.41) 0.026 1.65 (1.39-1.96) <0.001

Widowed 1.01 (0.78-1.34) 0.89 1.50 (1.13-1.99) 0.005

Divorced 1.08 (0.90-1.29) 0.40 1.50 (1.24-1.81) <0.001

Discussion

19. Start the discussion with a summary of the key results of your study and then move on to discuss them in light of other relevant literature.

20. The findings from this paper may be helpful to your discussion and conclusion. Consider citing it as well.

Ng'ambi W, Mangal T, Phillips A, Colbourn T, Mfutso-Bengo J, Revill P, Hallett TB. Factors associated with healthcare seeking behaviour for children in Malawi: 2016. Trop Med Int Health. 2020 Dec;25(12):1486-1495. doi: 10.1111/tmi.13499. Epub 2020 Oct 19. PMID: 32981174.

21. Don’t repeat results in the discussion but rather compare your key results with those of other studies and explain any disparity or agreement.

Conclusion

22. This section should provide policy insights as well as alignment of the study findings with the SDGs as well as universal health coverage.

23. Include the policy relevance of your study findings as well.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #4: Yes: Wingston Felix Ng’ambi

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31 Jul 2021

Response to the reviewer and editor

Date: July 31, 2020

To the Editor,

PLOS ONE Journal

Greetings! Hope you are fine and doing well. First of all, I would like to thank both the editor and reviewers for the extensive review of our manuscript and providing us opportunities to revise it. For the revision of this manuscript, I took the support of my colleagues Dr. Sushil Pokhrel and Dr. Ganesh Tiwari. We have tried to incorporate all the feedback provided in the revised version of the manuscript. I have mentioned my response in comment of the reviewers and editor. Now, I am submitting the revised version of the manuscript as well as the original version with track changes. Thank you very much for your time and consideration.

Best regards!

Ganga Tiwari

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Author’s response: I have reviewed the reference list. It is complete and do not include the retracted article,

Reviewer's Responses to Questions

1. The title should be changed to “Factors associated with healthcare seeking behavior for common illnesses amongst under-five children in Surkhet district, Nepal: 2018“

Author’s response: I have changed the title accordingly.

2. The manuscript needs to be numbered in order to reference to line numbers. This makes review easier.

Abstract

Introduction of abstract

3. “There are few studies on health care seeking behavior among caretakers in Nepal, so the objective of this study was to itsassess the healthcare-seeking behavior of the caretakers in Birendranagar municipality of Surkhet district. So, this study aims to identify prevailing health care seeking behavior of caretakers on perceived illness of under five year children and to identify the association of socio demographic, economic, illness related and health system related factors with health care seeking behavior.” Should be changed to “There are few studies on healthcare seeking behavior among caretakers in Nepal. Therefore, we conducted this study to determine the level of healthcare seeking behavior of caretakers on perceived illness and to identify the factors associated with health care seeking behavior of the caretakers of under five-year children from Surkhet district in Nepal in 2018.”

Author’s response: I have made slight change in the language of the objective and changed the objective, we did not determine the level, and we only determine the different health care seeking behaviors among the care takers.

Methods section of abstract

4. Add level of P-value for statistical significance

Author’s response: Previously, I had added level of p- value for statistical significance in abstract but previous reviewers of this journal suggested me to remove it from abstract so I have removed it.

5. How the logistic regression models were built (optional depending on word count)

Author’s response: Abstract become lengthy, if we add this detail

Results

6. Change “Regarding healthcare-seeking behavior of caretakers for their children’s illnesses, the most common source of care-seeking was visiting pharmacy directly at first (42.4 %), only one quarter (25.3 %) of the caretakers visited health facilities, among those who visited health facilities, only (37.2 %) of caretakers sought prompt health care.” to “Of these, 42.4% visited the pharmacy directly, 25.3% visited the health facilities and XXXX did nothing. Amongst those who visited a health facility, 37.2% of caretakers sought prompt health care.”

Author’s response: Thank you for your feedback; I have changed the result section accordingly.

Conclusion

7. Rather than just repeat the results consider using statements like (“There is a need to understand and address individual and socio-economic barriers to health seeking to increase access and use of health care and fast-track progress towards Universal Health Coverage amongst children from Surkhet district in Nepal.” This is what would be an appropriate conclusion that answers the question: How does this study relate to the SDGs and universal health coverage as well as Nepal National Health Strategy?

Author’s response: Since, this study is confined to Birendranagar Municipality of Surkhet district, we have concluded according to our study results at the municipality level. Now, we have also included policy implication of our study.

Main body of the paper

8. Include a running title of the paper

Introduction

9. Change the objectives as stipulated in the abstract

Methods

10. p-value should be changed to P-value

11. The authors should make it clear how they arrived at the final model. Did they use log likelihood ratio methods or some other methods? They also need to be clear on what multivariate analysis that they are conducting.

Author’s response:

We used SPSS for the data analysis. The twelve variables (ethnicity, educational status, occupation, socioeconomic status, distance to reach nearest health facility, place of delivery, perceived severity, history of difficulty breathing, knowledge on danger signs, number of symptoms, duration of illness, number of children) that exhibited significant association with health care seeking in bivariate analysis i.e. p value ≤ 0.2 were further analyzed in multivariate analysis using binomial logistic regression. Multivariate analysis was done for adjustment of possible confounders. Hosmer Lemeshow test, the goodness of fit of the model was assessed. The test statistic was 0.500 (>0.05) that showed that the model adequately fits the data.

12. Under a subsection “Appropriate health care seeking behavior” several studies include obtaining care from pharmacies as appropriate health care seeking behaviour (HSB), how come you are doing this differently?

Author’s response: We also took references of several studies, obtaining medicines from pharmacies without prescription/doctor’s consultation is considered as in-appropriate health care seeking behavior. Obtaining medicines from pharmacies without any consultation comes under self- medication, because of this irrational use of medication; antibiotic/drug resistance is a big issue in Nepal, We had taken the reference of studies from Yemen, India and North- West Ethiopia. Full citations of these studies are mentioned below.

Kalita D, Borah M, Kakati R, Borah H. Primary Caregivers Health Seeking Behaviour for Under-Five Children : A Study in a Rural Block of Assam, India. Ntl J Community Med. 2016;7(11):868–72.

Webair HH, Bin-Gouth AS. Factors affecting health seeking behavior for common childhood illnesses in Yemen. Patient Prefer Adherence. 2013;7:1129–38.

Molla Simieneh M, Mengistu Y, Gelagay AA, Gebeyehu MT. Mothers’ health care seeking behavior and associated factors for common childhood illnesses, Northwest Ethiopia: community based cross-sectional study.

13. Can you refer to “Ng'ambi W, Mangal T, Phillips A, Colbourn T, Mfutso-Bengo J, Revill P, Hallett TB. Factors associated with healthcare seeking behaviour for children in Malawi: 2016. Trop Med Int Health. 2020 Dec;25(12):1486-1495. doi: 10.1111/tmi.13499. Epub 2020 Oct 19. PMID: 32981174.” for some operational definition of HSB.

Author’s response: As we had conducted this study on 2018, we had defined operational definitions ourselves before the conduction of study taking reference of relevant literature, now study have already conducted, we can’t modify our operational definitions. Operational definitions are always defined before the conduction of study, not after the completion of study, as operational definitions involves variables; these are set before data collection.

Results

14. Format the tables for characteristics to look like this.

Patient characteristics n (%)

Total 255229 (100.0)

Gender

Male 122610 (48.0)

Female 125275 (49.1)

Missing 7344 (2.9)

Location

Rural 168258 (65.9)

Urban 86971 (34.1)

Age at Sample draw (in months)

0-1 145622 (57.1)

2-5 74707 (29.3)

6-11 21307 (8.4)

12-17 3337 (1.3)

18-24 1902 (0.8)

Missing 8354 (3.3)

Region

Northern 22897 (9.0)

Central 72,633 (28.5)

Southern 159699 (62.6)

Year Sample drawn

2013 16308 (6.4)

2014 25858 (10.1)

2015 41271 (16.2)

2016 41178 (16.1)

2017 42252 (16.6)

2018 43370 (17.0)

2019 36372 (14.3)

2020* 7741 (3.0)

Missing 879 (0.3)

15. In all tables do not combine the mean or SD if the headings are number and percentage

Author’s response: Thank you for your feedback, I have updated the tables accordingly.

16. All tables should not have lines crossing them

Author’s response: Thank you for your feedback, I have updated the table accordingly.

17. Include the illnesses (like fever, diarrheas) as appriori variables in the final multivariate model as these form key part of your analysis. Also include age and sex of the child as appriori variables.

18. We are not sure of the P-value for Table 5. Is it for crude or adjusted estimates? I would format the table to look like:-

Characteristics (n=26386) Bivariate analysis Multivariate analysis

OR (95%CI) P-value OR (95%CI) P-value

Age group

15-19 1.00 1.00

20-24 1.10 (1.00-1.21) 0.06 1.26 (1.13-1.41) <0.001

25-29 1.07 (0.96-1.18) 0.22 1.42 (1.24-1.62) <0.001

30-34 1.06 (0.95-1.18) 0.33 1.48 (1.27-1.72) <0.001

35-39 1.07 (0.95-1.21) 0.27 1.61 (1.36-1.92) <0.001

40-44 0.91 (0.78-1.07) 0.25 1.47 (1.19-1.81) <0.001

45-49 1.02 (0.80-1.30) 0.88 1.77 (1.33-2.34) <0.001

Year

2004/5 1.00 1.00

2010 1.23 (1.14-1.32) <0.001 1.21 (1.12-1.31) <0.001

2015/16 2.19 (2.03-2.37) <0.001 2.12 (1.97-2.29) <0.001

Region

North 1.00

Centre 1.03 (0.94-1.12) 0.55

South 0.96 (0.88-1.05) 0.40

Number of previous children ever born

1 1.00 1.00

2-3 0.79 (0.74-0.85) <0.001 0.70 (0.64-0.76) <0.001

4-5 0.74 (0.68-0.80) <0.001 0.62 (0.55-0.70) <0.001

6+ 0.69 (0.63-0.75) <0.001 0.59 (0.51-0.69) <0.001

Education level

None 1.00 1.00

Primary 1.22 (1.13-1.32) <0.001 1.09 (1.00-1.18) 0.05

Secondary 1.69 (1.54-1.86) <0.000 1.24 (1.11-1.39) <0.001

Tertiary 4.36 (3.42-5.57) <0.001 2.35 (1.80-3.06) <0.001

Wealth index quintile

Poorest 1.00 1.00

Poorer 1.07 (0.99-1.16) 0.10 1.07 (0.99-1.17) 0.09

Middle 1.09 (1.00-1.18) 0.05 1.10 (1.01-1.20) 0.024

Richer 1.17 (1.07-1.28) <0.001 1.15 (1.05-1.26) 0.002

Richest 1.47 (1.35-1.60) <0.001 1.23 (1.11-1.36) <0.001

Residence

Urban 1.00

Rural 0.78 (0.72-0.84) <0.001

Sources of antenatal care knowledge

Frequency of listening to radio

Less than once a week 1.00

At least once a week 1.00 (0.95-1.05) 0.97

Frequency of watching television

Less than once a week 1.00 1.00

At least once a week 1.44 (1.31-1.58) <0.001 1.13 (1.02-1.26) 0.025

Barriers to access antenatal care

Permission to visit health services

No problem 1.00

Big problem 1.10 (1.02-1.19) 0.01

Money to pay for health services

No problem 1.00

Big problem 0.88 (0.83-0.92) <0.001

Distance to health facilities

No problem 1.00

Big problem 0.93 (0.88-0.98) 0.005

Presence of companion

No problem 1.00

Big problem 0.98 (0.92-1.04) 0.50

No drugs at health facility

No problem 1.00

Big problem 1.28 (1.21-1.35) <0.001

No female provider

No problem 1.00

Big problem 1.01 (0.95-1.09) 0.64

Marital status

Never married 1.00 1.00

Married 1.20 (1.02-1.41) 0.026 1.65 (1.39-1.96) <0.001

Widowed 1.01 (0.78-1.34) 0.89 1.50 (1.13-1.99) 0.005

Divorced 1.08 (0.90-1.29) 0.40 1.50 (1.24-1.81) <0.001

Author’s response: It is not crude, it is adjusted estimates.

Discussion

19. Start the discussion with a summary of the key results of your study and then move on to discuss them in light of other relevant literature.

20. The findings from this paper may be helpful to your discussion and conclusion. Consider citing it as well.

Ng'ambi W, Mangal T, Phillips A, Colbourn T, Mfutso-Bengo J, Revill P, Hallett TB. Factors associated with healthcare seeking behaviour for children in Malawi: 2016. Trop Med Int Health. 2020 Dec;25(12):1486-1495. doi: 10.1111/tmi.13499. Epub 2020 Oct 19. PMID: 32981174.

21. Don’t repeat results in the discussion but rather compare your key results with those of other studies and explain any disparity or agreement.

Conclusion

22. This section should provide policy insights as well as alignment of the study findings with the SDGs as well as universal health coverage.

23. Include the policy relevance of your study findings as well.

Author’s response: We have included policy relevance of our findings in the conclusion section.

Submitted filename: Response to the reviewers.docx

Click here for additional data file.

16 Feb 2022

Health care seeking behavior for common childhood illnesses in Birendranagar municipality, Surkhet, Nepal

PONE-D-20-18110R3

Dear Dr. Tiwari,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Filiberto Toledano-Toledano, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #4: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #4: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #4: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #4: 1. They need to round the AOR to two decimal places.

2. AOR should be put in full as it is appearing for the first time.

3. The study variables should be put in a box. The current presentation does not make them look sexy.

4. Illnesses interact and their co-existence affects the HSB, may you refer to the paper by Ng’ambi et al (https://onlinelibrary.wiley.com/doi/epdf/10.1111/tmi.13499) and this could be another nice reference for your work.

5. The tables need proper formatting (refer to https://onlinelibrary.wiley.com/doi/epdf/10.1111/tmi.13499)

6. The figures need to have the titles.

7. It is not clear how the variables were selected into the model.

8. One limitation of the paper is that they only looked at two illnesses. The authors should check (https://onlinelibrary.wiley.com/doi/epdf/10.1111/tmi.13499) where a multiplicity of illnesses have been looked at.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #4: Yes: Wingston Ng’ambi, Research Scientist- University of Geneva; Lecturer at Kamuzu University of Health Sciences

21 Mar 2022

PONE-D-20-18110R3

Health care seeking behavior for common childhood illnesses in Birendranagar municipality, Surkhet, Nepal: 2018

Dear Dr. Tiwari:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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on behalf of

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PLOS ONE