Tumusiime et al.

BMC Pediatrics (2024) 24:403 BMC Pediatrics

https://doi.org/10.1186/s12887-024-04879-9

RESEARCH Open Access

Time to treatment-seeking by caretakers

of children under-five with diarrhea
and associated factors in Uganda: a multilevel
proportional hazards analysis
Sula Tumusiime1* , John Bosco Asimwe1, Leonard Atuhaire1, Ronald Wasswa1, Dick Nsimbe1 and Brian Kayera1

Abstract
Background Diarrhea is considered to be one of the major public health concerns in developing countries. It has a
detrimental impact, reflecting one of the highest child mortality rates globally, especially in Sub-Saharan Africa, where
2 out of every 10 children in Uganda under the age of five die. The objective of this study was to investigate the
factors associated with time to treatment seeking by caretakers of children under-five with Diarrhea in Uganda.
Method DOVE dataset of 745 caretakers in a prospective and retrospective incidence-based study using multi-stage
sampling design was used in the assessment. The analysis was done using a time-to-event approach using life tables,
Kaplan Meier survival analysis and multilevel proportional hazards model.
Results Kaplan-Meier survival analysis indicated the median time to seeking treatment among 745 caretakers
of children under-Five after onset of diarrhea was 2 days. The multi-level proportional hazards model of a Weibull
distribution showed that the estimated frailty variance was 0.13, indicating heterogeneity of treatment seeking time
by caretakers of under-five children with diarrhea across regions in Uganda. Significant factors found to influence time
to treatment-seeking by caretakers of children under-five with diarrhea were, male children (HR = 0.82; 95% CI = 0.71–
0.95, p = 0.010), belonging to richest wealth quintile (HR = 1.37; 95% CI = 1.05–1.78, p = 0.022), and residing more than
5 km away from a health facility (HR = 0.68; 95% CI = 0.56–0.84, p = 0.000).
Conclusions There are delays in seeking diarrhea treatment in Uganda because two days are enough to claim a life
after dehydration.The policymakers should pay attention to formulate effective intervention to sensitize caregivers
on the importance of early treatment-seeking behavior to avoid severe malnutrition caused by diarrhea. Community
awareness program should also be encouraged particularly in areas of more than 5 km from the health facility to
make people aware of the necessity to take prompt action to seek care in the early stage.
Keywords Childhood diarrhea, Caretakers, Treatment seeking, Multilevel-proportional-hazards, Uganda

*Correspondence:
Sula Tumusiime
sulatumusiime1@gmail.com
1
Department of Statistical Methods and Actual Science, School of
Statistics and Planning, Makerere University, P.O.Box 7062, Kampala,
Uganda

© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use,
sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and
the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this
article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included
in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The
Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available
in this article, unless otherwise stated in a credit line to the data.
Tumusiime et al. BMC Pediatrics (2024) 24:403 Page 2 of 7

Background Methods
Diarrheal diseases contribute to 1 in 9 child deaths glob- This study used secondary data from the DOVE study
ally, making it the second leading cause of mortality conducted by Makerere University School of Pub-
among children under 5 years old [1]. According to Liu et lic Health in partnership with Johns Hopkins School of
al. (2015), of the 6.3 million deaths recorded in children Public Health. The (2017–2018) DOVE study used a
under 5 worldwide in 2013, 10% were linked to diarrhea, prospective and retrospective incidence-based study. A
resulting in a daily toll of up to 2,195 children, surpass- multi-stage sampling design was used to reach health
ing the combined fatalities from AIDS, malaria, and facility and simple random sampling technique was used
measles [2]. The majority of these childhood deaths are to select 48 health centers. Four districts were selected
concentrated in South Asia and Africa [3]. The diarrhea from 4 regions (Northern, Eastern, and Western & Cen-
mortality rate per 100,000 children exhibited a signifi- tral), 12 health facilities were then selected from each dis-
cant decline of 69.6% from 1990 to 2017.Contributors to trict bringing the total number of health facilities to 48.
the decline in diarrhea mortality rates include improve- A sample of 15 caretakers of children under 5 years with
ments in sanitation, reduction in childhood wasting, and diarrhea in Uganda was then selected from each health
increased availability and use of oral rehydration solution facility, bringing the total number of caretakers who were
(ORS) [4]. Despite the effectiveness of ORS in reducing interviewed to 745 for both the patient caretaker exit sur-
diarrhea-related deaths, challenges persist in ensuring vey and the patient caretaker follow-up survey. In order
widespread access and utilization of this life-saving inter- to ensure that data collected was geographically repre-
vention. Financial constraints often hinder access to ORS sentative of the country and logically feasible, Kampala
and other essential healthcare services, exacerbating the district from Central region, Gulu district from Northern
burden of diarrhea morbidity and mortality, particularly region, Mbarara district from Western region and Jinja
among economically disadvantaged populations. district from Eastern region. Facilities in each selected
Rotavirus stands as the primary contributor to severe district were selected across all levels to ensure represen-
childhood diarrhea, causing an estimated 192,700 deaths tativeness of hospitals, HCIV, HCIII and HCII. Health
annually, with approximately 50% of these fatalities facilities from all levels were selected to appropriately
concentrated in the World Health Organization Africa represent rural and urban locations. Representativeness
Region [5]. The World Health Organization (WHO) fur- of type of ownership of facilities including private for
ther projects that 7.3% of deaths among children under 5 profit, private not for a profit and public facility was also
in Uganda and 6.4% in Kenya can be attributed to rotavi- accounted for.
rus [6]. The introduction of rotavirus vaccines emerges as
a pivotal strategy to significantly mitigate childhood mor- Measures of outcome
bidity and mortality. Post-introduction studies conducted The dependent variable was time to treatment-seeking
in the USA and other regions have underscored the posi- by caretakers of children under five with diarrhea. The
tive impact of vaccine implementation, particularly in period was measured from time of onset of diarrhea up
reducing the disease burden, notably through a decline in to the time the caretaker sought treatment in days.
rotavirus-related hospitalizations. In Uganda, spanning
from 2016 to 2033, the adoption of the rotavirus vaccine Measures of explanatory variables
holds the potential to prevent approximately 4 million The independent variables were socio-economic and
cases of rotavirus diarrhea and avert 70,236 deaths [6]. structural characteristics of caretakers and children
In Uganda, studies and reports on child morbidity below the age of five years with diarrhea. The socio eco-
and mortality have consistently shown that diarrhea is a nomic factors include the age of the child categorized
major public health concern [7]. In 2008, it was reported as < 6 months, 6–11, 12–23, and > 24 months; the gen-
that 16% of all deaths among children under 5 in Uganda der of the child indicated as female and male; the age of
were attributed to diarrhea [8]. The lack of accessible and the caretaker recorded as 17–26 years, 27–36, 37–46,
adequate health facilities to handle diarrhea cases has and > = 47 years; the gender of the caretaker recorded as
contributed to a significant number of child deaths [9]. female and male; the education level of the caretaker cat-
According to the 2016 Uganda Demographic and Health egorized as no education, primary level, secondary level,
Survey, 23% of children in Uganda had experienced diar- higher/tertiary level; marital status recorded as single,
rhea in the two weeks preceding the national survey [10]. married, and others; Region categorized as Northern,
It’s against this background, our study aimed to investi- Eastern, Western, and Central region; occupation coded
gate factors associated with the time to seek treatment as agriculture, business, formal employment, and others
among children under five with diarrhea in Uganda. and Wealth quintile recorded as poorest, poor, medium,
rich, and richest. The wealth quintile status of each
household was defined based on asset scores generated
Tumusiime et al. BMC Pediatrics (2024) 24:403 Page 3 of 7

through a principle component analysis (PCA) approach. a standard parametric such as the Exponential, Weibull
The PCA considered the ownership of durable assets in or Gompertz distributions or more general spline based
the households: the households’ dwelling characteris- approach; XijT β are the fixed effects and ZijT bj are ran-
tics (e.g., wall, roof and or materials, water and sanita- dom effects. The random effects follow  a multivari-
tion facilities, and utilities) and durable goods (e.g., radio ate normal distribution, with bj ∼ N(0, ). The Akaike
and television). Based on their asset score ranking, the Information Criterion (AIC) was used to obtain the best
households were divided into asset quintiles indicating model. This is a statistic that is used when comparing
the wealth status of the household. The structural factors the viability of different parametric models. For a set of
include health facility indicated as government and pri- models, the one with lower value of AIC, suggests a bet-
vate; and distance to health facility (km) categorized as ter model.
(0–5)km and > 5 km.
Results
Statistical analysis An analysis of the pattern of survival time was conducted
A survival data analysis approach was adopted in the by grouping them into overlapping intervals of 2 days.
investigation. Prior to the analysis, a survival variable Table 1 reveals that out of 745 caretakers, approximately
was generated. A survival variable represented those who 34% (250) sought treatment within (0–2) days, while 66%
sought treatment and all observations were coded 1 since (495) delayed in seeking treatment.
there was no censoring problem. The analysis was car- Fig. 1 shows that the median time to seeking treatment
ried out at three stages: First, summary statistics, Kaplan was 2 days, which implies that caretakers among children
Meier and life table was adopted for describing the prob- under five with diarrhea spent on average 2 days before
ability of seeking treatment [11]. Secondly, differentials in seeking treatment.
time to treatment seeking by socio-economic and struc-
tural characteristics was assessed using the Log-rank test. Differentials in survival times
Associations was established at 5% level of significance Table 2 presents the distribution of time spent seeking
using the general format for the Log-rank test statistics treatment of caretakers among children under five with
for categorical variables. Third, the influence of socio- diarrhea based on socio-economic and structural char-
economic factors and structural factors on time to seek- acteristics among the study participants. The survey
ing treatment was assessed using multilevel proportional involved a total of 745 caretakers of children under five
hazards model. The motivation for the frailty model was with diarrhea. The results show that 38% children aged
because of time to event clustered data with regions as between 6 and 11 months and approximately 14% hav-
clusters. ing infants less than 6 months old. Gender-wise, about
53% of the children were male, and 47% were female. The
hij (t|X) = ho (t)exp (XijT β + ZijT bj ) majority (53%) of caretakers were aged between 17 and
26 years, with only a small fraction (about 1%) aged 47
Where hij (t| X) is the survival time or the probability years and above. Furthermore, Females comprised the
of seeking treatment of the j th patient in the ith cluster majority of caregivers, accounting for 93%. Educationally,
(Regions); ho (t) is the baseline hazard function of either the majority (41%) had attained a primary level of educa-
tion, while 5% had no formal education. Geographically,
Table 1 Time to treatment-seeking by caretakers of children approximately 71% of the participants resided in urban
under-five with diarrhea in Uganda (N = 745) areas, and the majority (85%) were married. The distribu-
Inter- Total Caretakers The Probabil- The Probabili- tion of caretakers by regions was as follows: 24% from the
val Caretak- that Sought ity of seeking ty of not seek-
(Days) ers at Treatment at treatment at ing treatment
Northern region, 21% from the Eastern region, 28% from
time(t) time(t) time(t) at time (t) the Western region, and 27% from the Central region.
0–2 745 250 0.337 0.664 Regarding wealth quintile, the majority (21%) were from
2–4 495 295 0.596 0.268 poorest quintile, and 38% were engaged in business
4–6 200 84 0.420 0.156 occupations. Health facility utilization showed that 55%
6–8 116 84 0.724 0.043 of participants sought care from government facilities,
8–10 32 6 0.188 0.035 while private facilities were less frequently utilized. The
10–12 26 2 0.077 0.032 results also show that nearly (84%) had to travel 0–5 km
12–14 24 2 0.083 0.030 to reach the nearest health facility.
14–16 22 19 0.864 0.004 Differentials were assessed based on socio-economic
20–22 3 1 0.333 0.003 and structural factors using the log-rank test for all cat-
28–30 2 1 0.500 0.001 egorical variables. This assessment aimed to determine
30–32 1 1 1.000 0.000 which variables should be considered for multivariate
Tumusiime et al. BMC Pediatrics (2024) 24:403 Page 4 of 7

Fig. 1 Kaplan meier survival estimates for time to seeking treatment

Source: authors computation

analysis. The results of the factors considered for multi- were incorporated into the model as indicated in Table 3.
variate analysis revealed significant associations with the These factors include the age of the child, gender of the
time spent seeking treatment among caretakers of chil- child, education level of the caretaker, region, wealth
dren under five with diarrhea. Age of the child exhibited quintile, and distance to the health facility. We found that
a statistically significant relationship (p = 0.028), indicat- caretakers with male children were more likely to delay
ing that different age groups may have distinct patterns in seeking treatment compared to those with female chil-
in seeking treatment. Similarly, the gender of the child dren (HR = 0.82; 95% CI = 0.71–0.95, p = 0.010). The haz-
showed significance (p = 0.049), suggesting gender-spe- ard ratio (HR = 0.82) decreases among caretakers with
cific differences in treatment-seeking behavior. Educa- male children implying longer time to seeking treatment.
tion level of the caretaker also played a significant role Furthermore, caretakers in the richest wealth quintile
(p = 0.033), indicating variations in treatment-seeking were more likely to seek treatment for their children early
tendencies based on the caretaker’s education. Geo- compared to those in the poorest quintile (HR = 1.37; 95%
graphically, the region of residence showed a highly sig- CI = 1.05–1.78, p = 0.022). The hazard ratio (HR = 1.37)
nificant association (p = 0.000), emphasizing the influence increases among caretakers belonging to the richest
of geographical location on treatment-seeking timing. wealth quintile indicating shorter time to seeking treat-
Additionally, wealth quintile demonstrated significance ment. Regarding distance, caretakers living in more than
(p = 0.012), indicating the impact of socio-economic sta- 5 km from the health facility were more likely to delay in
tus on treatment-seeking behavior. Finally, distance to seeking treatment compared to those residing between 0
the health facility was significantly associated (p = 0.002), and 5 km to the health facility (HR = 0.68; 95% CI = 0.56–
highlighting the influence of proximity to healthcare 0.84, p = 0.000). The hazard ratio (HR = 0.68) decreases
facilities on treatment-seeking decisions. implying longer time to seeking treatment for caretak-
ers living in more than 5 km from the heath facility. The
Risk factors for time to seeking diarrhea treatment among estimated frailty variance was 0.13, indicating heteroge-
children under five in Uganda neity of treatment seeking time across the four regions
To identify the net effect of each independent factor on in Uganda. Regarding the diagnostic test, the Akaike
the time to seeking treatment, a multilevel proportional Information Criterion (AIC) of the Weibull model had
hazards model was employed, utilizing the risk fac- the lowest value at 1783.951, in contrast to the AIC of the
tors identified in the bivariate analysis. In this context, exponential model, which stood at 3112.541. Therefore,
all significant independent factors at the bivariate level
Tumusiime et al. BMC Pediatrics (2024) 24:403 Page 5 of 7

Table 2 Differentials in time to seeking treatment by socio- Table 3 Factors associated with time to treatment seeking by
economic and structural Factors caretakers of children under-five with diarrhea in Uganda
Covariates N Percentage Log-rank Covariates Hazards P-Value 95% CI
distribution 𝑐h𝑖2, 𝑝 Ratio(HR)
Age of child (months) Age of child (months)
<6 102 13.7 < 6 (Ref.) 1.00 - -
6–11 193 25.9 6–11 1.01 0.948 0.79–1.29
12–23 283 37.9 9.09 12–23 1.15 0.251 0.91–1.44
> 24 167 22.4 (p = 0.028) > 24 1.25 0.084 0.97–1.60
Age of caretaker Gender of child
17–26 395 53.0 Female (Ref.) 1.00 - -
27–36 292 39.2 Male 0.82 0.010 0.71–0.95
37–46 48 6.4 2.88 Education level of caretaker
>=47 10 1.3 (p = 0.410) No education (Ref.) 1.00 - -
Gender of child Primary level 0.87 0.436 0.61–1.24
Female 344 46.8 3.89 Secondary level 0.87 0.474 0.60–1.27
Male 391 53.2 (p = 0.049) Higher/Tertiary level 1.10 0.644 0.73–1.66
Gender of caretaker Wealth Quintile
Female 694 93.2 (1.69) Poorest (Ref.) 1.00 - -
Male 51 6.8 (p = 0.194) Poor 1.22 0.123 0.95–1.56
Education level of caretaker Medium 1.03 0.832 0.80–1.32
No education 36 4.8 Rich 1.01 0.957 0.77–1.31
Primary level 302 40.5 Richest 1.37 0.022 1.05–1.78
Secondary level 289 38.8 8.72 Distance to Health facility (km)
Higher/Tertiary level 118 15.8 (p = 0.033) 0–5 (Ref.) 1.00 - -
Residence >5 0.68 0.000 0.56–0.84
Rural 218 29.3 2.86 Region 0.13 0.03–0.55
Urban 527 70.7 (p = 0.091) var(_cons)
Marital Status (Ref.) = reference category, CI = confidence interval

Single(unmarried) 64 8.6
Married 633 85.0 1.20 we reported and based our research findings on the
Others 48 6.4 (p = 0.548) Weibull model due to its lower AIC.
Region
Northern 181 24.3 Discussion
Eastern 159 21.3 This study aimed to explore the Time to Treatment-
Western 205 27.5 74.31
Seeking by Caretakers of Children Under-Five with Diar-
Central 200 26.8 (p = 0.000)
rhea and associated factors in Uganda using a Multilevel
Wealth Quintile
Proportional Hazards Model. The results of the study
Poorest 153 20.6
revealed that the median time to seek treatment was 2
Poor 143 19.3
days (range, 1–30 days) from the onset of diarrhea. As for
Medium 149 20.0
the estimated frailty variance was 0.13, indicating hetero-
Rich 146 19.7 12.79
geneity across regions. Gender of the child, wealth quin-
Richest 151 20.4 (p = 0.012)
tile and distance to the health facility were the factors
Occupation
Agriculture 86 11.8
associated with time to seeking treatment by caretakers
Business 273 37.5
of children under five with diarrhea in Uganda.
Formal employment 167 22.9 4.91
Specifically, caretakers with male children were more
Others 203 27.8 (p = 0.178) likely to delay in seeking treatment compared to those
Health Facility with female children. This finding contrasts with the
Government 410 55.0 1.70 results of Sarker et al. (2016), who reported that male
Private 335 45.0 (p = 0.192) children were 2.09 times more likely to receive care than
Distance to Health facility (km) female children. However, this disparity can be explained
0–5 625 83.9 9.67 by the mothers’ level of education. Educated women are
>5 120 16.1 (p = 0.002) better equipped to break away from traditional prac-
All 745 100 tices and utilize modern means to safeguard their chil-
dren’s health. They can also make independent decisions
Tumusiime et al. BMC Pediatrics (2024) 24:403 Page 6 of 7

regarding their children’s health, leading to better health to seek treatment for their children earlier than those
outcomes for children, regardless of their gender [12]. belonging to the poorest category. However, caretakers
Furthermore, caretakers in households belonging to with male children and those living in more than 5 km
the richest category were more likely to seek treatment from the health facility were more likely to delay in seek-
for their children earlier than those in the poorest cat- ing treatment. The policymakers should pay attention to
egory. These findings align with previous studies [4, 7], formulate effective intervention to sensitize caregivers
where it was observed that families with lower income on the importance of early treatment-seeking behavior
were less likely to seek timely healthcare due to higher to avoid severe malnutrition caused by diarrhea. Com-
expenditures and an inability to afford medical costs. The munity awareness program should also be encouraged
reason might be lower-income households often turn to particularly in areas of more than 5 km from the health
unqualified or traditional healthcare providers for their facility to make people aware of the necessity to take
children’s medical needs because of the lower cost, easy prompt action to seek care in the early stage.
accessibility, and familiarity of these services in their
Abbreviations
areas [12]. This could also be due to the fact that eco- AIC Akaike Information Criterion
nomically disadvantaged households typically seek medi- DOVE Decade of Vaccination Economics
cal care for their children based on the perceived severity HC Health Centers
HH Household
of illness, unlike wealthier households where regular HR Hazard Ratio
medical checkups are scheduled. ICF International Classification of Functioning, Disability and Health
Lastly, caretakers living in more than 5 km from the KM Kilometers
MDG Millennium Development Goal
health facility were more likely to delay in seeking treat- ORS Oral Rehydration Solution
ment compared to those residing between 0 and 5 km to OR Odds Ratio
the health facility. These findings align with the results of PCA Principle Component Analysis
p-value/p Probability Value
Kassile et al. (2014), who found that children living at a U5 Under five years
distance of > 5 km from the nearest health facility were UBOS Uganda Bureau of Statistics
twice as likely to delay seeking medical care compared to USAID United States Agency for International Development
UN United Nations
those living closer. This variation can be attributed to the
distance from suitable healthcare facilities near their resi- Acknowledgements
dence, potentially increasing out-of-pocket expenses for The authors extend their sincere gratitude to Makerere University School of
Public Health and Johns Hopkins School of Public Health for allowing them to
transportation and further discouraging caregivers from access Decade of Vaccination Economics data .
seeking early treatment [13].
Our present study has some limitations. The study Author contributions
Author Contributions Statement: In accordance with our authorship policy for
did not employ a mixed methods analysis, incorporat- BMC Pediatrics, each author’s contributions to this manuscript are specified
ing both qualitative and quantitative approaches, which below: Sula Tumusiime (S.T.): S.T. served as the corresponding author and
could have offered a more comprehensive understanding played a pivotal role in the study’s conception and design, data acquisition,
analysis, and interpretation. S.T. also led the initial drafting of the manuscript
of treatment-seeking behaviors. In addition, the DOVE and coordinated revisions based on input from all co-authors; John Bosco
study’s utilization of cross-sectional data warrants care- Asimwe (J.B.A.): J.B.A. Conceptualized and designed the research study,
ful consideration. Although the reported factors are asso- analysis, and contributed to the interpretation of findings. J.B.A. also provided
critical feedback during the manuscript’s review and revision process;
ciated with the outcome, caution must be exercised in Leonard Atuhaire (L.A.): L.A. Conceptualized and designed the research study,
assuming causality. Future research endeavors, particu- played a significant role in the statistical analysis and the interpretation of
larly longitudinal studies, are needed to ascertain causal results. L.A. contributed to the manuscript’s development by providing
valuable insights and revisions; Ronald Wasswa (R.W.): R.W. contributed to
relationships and explore temporal variations in health- statistical analysis, enhancing the research’s integrity. R.W. actively participated
care-seeking behaviors. in reviewing and improving the manuscript; Brian Kayera (B.K.): B.K. was
instrumental to the manuscript’s introduction and discussion sections. K.B.
played a key role in ensuring the accuracy and coherence of the research;
Conclusion Dick Nsimbe(D.N.): D.N. Analyzed the data, and interpreted the results. N.D.
The study showed that the median Time to Treatment- also made substantial contributions to the initial manuscript and played a
Seeking by Caretakers of Children Under-Five with key role in its revision based on input from co-authors and reviewers. Each
author contributed substantially to the intellectual content of the manuscript,
Diarrhea in Uganda was 2 days. There are delays in seek- ensuring its accuracy and integrity. They have read and approved the final
ing diarrhea treatment in Uganda because two days are version for submission. Please note that the roles and contributions of each
enough to claim a life after dehydration. In addition, author are based on their expertise and involvement throughout the research
process. Sincerely, Sula Tumusiime (S.T.); John Bosco Asimwe (J.B.A.); Leonard
gender of the child, wealth quintile, and distance to the Atuhaire (L.A.); Ronald Wasswa (R.W.); Dick Nsimbe (D.N.); Brian Kayera (B.K.)
health facility were the factors associated with Time to
Treatment-Seeking by Caretakers of Children Under- Funding
This study received no specific grant from any funding agency, commercial
Five with Diarrhea in Uganda. Specifically, Caretakers in entity or not-for-profit organization. However, the corresponding author
households belonging richest category were more likely is grateful to the College of Business and Management Science (CoBAMS),
Tumusiime et al. BMC Pediatrics (2024) 24:403 Page 7 of 7

Makerere University, for the institutional grant, as research facilitation support, 3. Carvajal-vélez L, et al. Diarrhea management in children under five in
for staff. sub-saharan Africa: does the source of care matter ? BMC Public Health.
2016;16(830):14. https://doi.org/10.1186/s12889-016-3475-1
Data availability 4. Memirie ST et al. Household expenditures on pneumonia and diarrhea treat-
The datasets used and/or analyzed during the current study available from the ment in Ethiopia: A facility-based study. BMJ Global Health, 2(1–10), 12https://
corresponding author on reasonable request. doi.org/10.1136/bmjgh-2016-000166. 2017.
5. Sarker AR, et al. Prevalence and Health Care-seeking behavior for Childhood
Diarrheal Disease in Bangladesh. Global Pediatr Health. 2016;3:1–12. https://
Declarations doi.org/10.1177/2333794X16680901
6. Sigei C, et al. Cost-effectiveness of rotavirus vaccination in Kenya and Uganda.
Ethics approval and consent to participate Vaccine. 2015;33(S1):A109–18. https://doi.org/10.1016/j.vaccine.2014.12.079
Utilizing secondary data with permission from Makerere University School 7. Taffa N, Chepngeno G. Determinants of health care seeking for childhood ill-
of Public Health and Johns Hopkins School of Public Health, the study was nesses in Nairobi slums. African Population and Health Research Center, Nairobi,
approved by DOVE Ethics Committee during the original survey. Moreover, Kenya, 10(3), 240–245https://doi.org/https://onlinelibrary.wiley.com/doi/
informed consent was obtained from all participants or their legal guardian(s) epdf/https://doi.org/10.1111/j.1365-3156.2004.01381.x. 2005.
as part of the data collection process. The study adheres to the ethical 8. Toure D. and G.M. S, The Millenium Development Goals Progress Report For
and consent procedures implemented by Makerere University School of Ugandahttps://doi.org/file:///C:/Users/Admin/Downloads/Uganda_MDGRe-
Public Health and Johns Hopkins School of Public Health. All procedures port_2003.pdf. 2015.
contributing to this research adhered to the ethical standards set by relevant 9. Troeger CE et al. Quantifying risks and interventions that have affected the bur-
national and institutional committees for human experimentation, as well as den of diarrhea among children younger than 5 years: An analysis of the Global
the Helsinki Declaration of 1975, amended in 2008. Burden of Disease Study 2017. The Lancet Infectious Diseases, 20(1), 37–59https://
doi.org/10.1016/S1473-3099(19)30401-3. 2020.
Consent for publication 10. Uganda Bureau of Statistics(UBOS). and ICF, Uganda Demographic and Health
Not applicable. Survey 2016.Kampala, Uganda and Rockville, Maryland, USA 2018.
11. Muhwezi K, Atuhaire LK. Retention of Academia at Makerere University: a
Competing interests Time-To-Event analysis. School Stat Plann Makerere Univ Uganda. 2017;54:45.
The authors declare no competing interests. https://doi.org/http://www.voiceofresearch.org/doc/Mar-2017/Mar-2017_13.
pdf.
Received: 6 November 2023 / Accepted: 10 June 2024 12. Nazmul M, Tarana HÆ. Maternal Education and Child Healthcare in Bangladesh.
Department of Statistics, Jahangirnagar University, Dhaka, Bangladesh, (12),
43–51https://doi.org/10.1007/s10995-007-0303-3. 2008.
13. Debsarma D, Saha J, Ghosh S. Factors associated with delay in treatment-
seeking behaviour for fever cases among caregivers of under-five children
References in India: evidence from the National Family Health Survey-4, 2015–16. PLoS
1. Bhutta ZA, et al. Evidence-based interventions for improvement of ONE. 2022;17(6):e0269844.
maternal and child nutrition: what can be done and at what cost? Lancet.
2013;382(9890):452–77. https://doi.org/10.1016/S0140-6736(13)60996-4
2. Black R, et al. Drivers of the reduction in childhood diarrhea mortality Publisher’s Note
1980–2015 and interventions to eliminate preventable diarrhea deaths by Springer Nature remains neutral with regard to jurisdictional claims in
2030. J Global Health. 2019;9(2):1–9. https://doi.org/10.7189/jogh.09.020801 published maps and institutional affiliations.