Health Behaviors and Care Seeking Practices for Childhood Diarrhea and Pneumonia in a Rural District of Pakistan: A Qualitative Study

"The community identified that intensive inclusive community engagement and demand creation strategies tied to conditioned short term tangible incentives could help foster behavior change."

Health-related behaviours are often resistant to change and are influenced by a variety of personal, cognitive, economic, socio-cultural, and structural factors. The use of formative research has increased to aid the implementation of culturally and geographically relevant intervention programmes. This qualitative study was conducted as part of the formative phase to inform the design of the Community Mobilization and Community Incentivization (CoMIC) cluster randomised controlled trial (RCT) in a rural district of Pakistan. The assessment sought to understand: the local community's knowledge and beliefs; the water, sanitation, and hygiene (WASH) conditions; infant and young child feeding (IYCF) and immunisation practices; and care-seeking behaviours for childhood diarrhoea and pneumonia. The goal was to highlight possible barriers and facilitators in the uptake of essential interventions, while exploring possible incentives that could improve community engagement and active participation to influence behaviour change.

Taking place in the Tando Muhammad Khan (TMK) district of Sindh, Pakistan, CoMIC is a prospective 3-arm cluster RCT with two intervention groups and a control group that is assessing the effect of a community engagement and demand creation strategy with a conditional collective community-based incentive (C3I) to improve care-seeking practices and adherence to prevention and management practices for diarrhoea and pneumonia in children under five years of age. The CoMIC research team was already present on site before the present study commenced, carrying out informal discussions within the community and identifying potential stakeholder groups.

The researchers carried out 23 in-depth interviews and 14 focus group discussions with a total of 157 key stakeholders using a semi-structured study guide. Among the findings:

• Socio-cultural context: The community residing in rural TMK belongs to a low socioeconomic background with limited access to basic amenities of life. Their focus towards survival leaves them with little or no energy to prioritise health care. Preventive measures are often ignored, and care is only sought in the event of disease or emergency.
• Community mobilisation: Participants showed significant interest in developing community groups to promote healthy practices and solve communal problems. They suggested that these groups may be in the form of village health committees, unions, or local organisations (tanzeem). Keeping in view the cultural and social characteristics of the community in TMK, participants believed that tribal differences and the lack of unity between community members could potentially hamper efforts to mobilise and create change. Thus, each group should have members with similar tribal identity and affiliations. To further promote the acceptability of group decisions and encourage positive outcomes, it was suggested that groups should be carefully formed to include able people who have influence and respect in the community, such as religious and tribal leaders, feudal lords, community elders and representatives, health providers, and teachers. Children were identified as agents of change, especially when it comes to sanitation and hygiene. Methods of message communication that were suggested included video and multimedia (brochures, pictorial messages, and flip charts). These methods would be most effective, especially keeping in mind the low literacy rate.
• Incentives: Although general community preference leans toward unconditional incentives, when the researchers discussed the potential of conditional non-cash incentives, participants agreed that this would be the best way to successfully promote healthy behaviours and practices in TMK. Examples of incentives proposed include construction of toilets and latrines, installation of hand pumps, and distribution of soap. When asked whether the community would contribute to these incentives, most declined monetary contribution but agreed to invest time, land, and labour. Such an approach could stimulate the residents to become involved in community activities, foster a sense of ownership, and promote solidarity.
• Childhood diseases: Most participants were aware of the causes, symptoms, and prevention of diarrhoea and pneumonia, but "sanitation and hygiene conditions are dismal in the region." Similar care-seeking behaviours for both diarrhoea and pneumonia were seen, where the community preferred receiving appropriate medical treatment from doctors and lady health workers (LHWs). However, cultural practices and misconceptions were present, indicating the need for awareness activities and the proposed community mobilisation and incentivisation intervention.
• IYCF: Efforts made by doctors and LHWs to increase awareness and dispel misconceptions has led to a decrease in the prevalent tradition of discarding colostrum. Now, some mothers breastfeed their infants when they have diarrhoea and pneumonia and are aware that breastfeeding should be continued for two years. The community believed that awareness programmes and village committees would be useful in educating women and the elders of the tribes, the latter of whom can join with doctors, LHWs, religious leaders, and landlords in promoting acceptability and uptake of improved health and nutrition behaviours.
• Immunisation: People tend to be aware that vaccines are mandated and that they can reduce the prevalence of various diseases. Although most children have been vaccinated, issues with complete and timely vaccination persist, largely due to logistical and behavioural reasons. For instance, there is a significant shortage of vaccinators in rural TMK, and LHWs are often included in vaccination campaigns to compensate for this shortage. The community gave mixed reviews regarding the frequency of visits and quality of services provided by LHWs. Most residents felt that LHWs are only concerned with the provision of vaccinations, especially the polio vaccine, and do not give due emphasis to hygiene, sanitation, water treatment, and illnesses like diarrhoea and pneumonia.

The findings derived from this formative research were discussed with the local community and used to design the intervention in the CoMIC trial, which involved collective community-based conditional non-cash incentives. As advised by the results of this study, the incentives were based on need assessment and prioritisation by the community themselves and were given only upon achieving improvement in the outcomes. Through this incentivisation and community mobilisation trial, we aimed to improve behavior patterns and care seeking practices for childhood diarrhoea and pneumonia in TMK.