A cross-sectional study of womens’ knowledge and reported practices on reproductive, maternal and child health in rural area of North-Eastern India

INTRODUCTION

After the publications in The Lancet in 2003, the topic of child health came to the forefront.^1-5 It was estimated that 10.8 million under-five children were dying globally in the year 2000. The 90% of these deaths were occurring in underdeveloped and developed nations of the world. The top causes for mortality were pneumonia and diarrhoea. Neonatal disorders and malaria were also the causes in few regions.¹ Around 63% of these can be prevented if the present knowledge can be transformed into effective action and empowering the woman.² The current neonatal and under-five mortality in India is 18.13 and 29.06 per 1000 live births which has marginally improved since 2021. The current maternal mortality ratio of India stands at 116.39 per 100000 live births which has worsened since 2018.⁶ The proposed target under sustainable development goals (SDGs) is to reduce neonatal mortality to as low as 12 and under-five mortality to as low as 25 by 2030.⁷ The WHO/UNICEF has agreed on certain indicators like oral rehydration therapy, continued feeding for diarrhoea, antibiotic treatment for pneumonia, malaria and its treatment and preventive measures and knowledge regarding breastfeeding.⁸ Evidence suggests that community based primary health care services can improve the chances of child survival in remote hard-to-reach areas.^9,10 These interventions is primarily targeted to improve knowledge and treatment seeking behaviour particularly among the woman. India started the home-based neonatal care (HBNC) and sepsis management by community health workers as a project in a rural area of Maharashtra, India and it showed a decline of 62% neonatal mortality compared to a neighbouring control group. Further, it was found that death due to neonatal sepsis declined from 16.6% to 2.8%.¹¹ In Nepal, an intervention using women’s health group led to a decline in 30% neonatal mortality. These women groups use to meet on a monthly basis and would discuss and identify problems and their effective solutions to tackle the issue.¹² Thus, evidence suggests that community health intervention programme and supervision of the workers lead to decline in neonatal and child mortality.

This study aims to understand the level of knowledge on child health and health seeking behaviour among the women of the study area. Secondly, this study also aimed to assess the effect of education and religion on the knowledge and behaviour.

METHODS

Study setting and participants

This study was conducted in the rural field practice area of the tertiary level teaching hospital of Assam, India. As of 2020 data, the rural field practice area caters a rural population of 36,405 in 40 villages with total rural households of 8,004.^13-15 Ten villages were purposively chosen for the study. Those were Abhaypur, Athiabai, Bonmaja, Dhopatari, Niz Sundari Ghopa, Rangmahal, Rudreswar, Sila, Silagrant and Silbharal. These ten villages covered almost 80% of the total rural population of the rural field practice area. From each selected village, 30 households were randomly selected and from those household, the woman were asked regarding their knowledge on health and their health seeking behaviour. If the woman was not present, then, the next household where the woman would be present will be selected for the study. If there was presence of more than one woman in household then only one woman would be randomly selected for the study. Thus, a total of 300 households were interviewed.

Data collection and sources

A pre-tested, pre-designed interview schedule was developed and data collection was done by trained field investigators. The interview schedule comprises of questions related to their housing, characteristics of the woman, knowledge on health, pregnancy, child health, and treatment seeking behaviour. The interview schedule was piloted in two nearby villages adjacent to the tertiary care teaching centre, namely Haluguri and Koroibari. The pilot testing led to necessary alteration of the translation of the interview schedule in the local language. Later, those villages were not considered in the final study.

Data analysis

Characteristics of the household and woman that included background details on households and demography were documented. Univariate analysis was done by frequencies and percentages for categorical data while mean, standard deviation and median for continuous data. Each correct response was awarded ‘1 point’ for those having a single correct answer. For the questions that had more than one correct option, then each correct response would be awarded reciprocal of the total number of correct answers thus making it to be a maximum of ‘1 point’ for each question. The addition of the scores would give an overall health knowledge score. Finally, regression analysis was performed with binary linear regression using education and caste of the woman to find the significant predictors that affected the health knowledge score. Age and persons per room were considered as continuous variables. Later, multiple linear regression was performed to see which factors influence the overall health score or acts as a confounder.

RESULTS

Descriptive statistics

The characteristics of 300 households documented that an average of 4 people and 2 children of under-five years lived in each household. An average of 2.1 persons shared a living room. A median of 2 bed-nets was used in each household. It also contained the observations made by the interviewer. A total of 294 (98%) households had a bed-net in place and it was also informed that the children in the household would be given the bed-nets to sleep. A total of 245 households (81.6%) had a hand-washing facility close to the place of preparing food, but only 17.1% had soap to wash hands near that water source. Only four out of ten households (38.4%) had presence of sanitary latrine facility and surprisingly, one-fifth (18.7%) did not have their own latrine facility (Table 1).

The mean age of the women in the study was 27.9±7.7 years with majority of the women belonging to Hindu religion. Majority of the women had completed their primary level of education and only 1.3% of the study population were illiterate (Table 2).

Health knowledge

The study population had poor knowledge on the prevention and management of diarrhoea as majority (7.6%) women gave only one correct response out of the possible four correct responses, 51% women said that they will not give more drinks to their child during diarrhoea and 52% have not heard about ORS. Only 34% of the women knew that breast milk should be given to child <6 months during diarrhoea episodes. Likewise, it was seen that the knowledge of women regarding malaria and pneumonia were good and almost half of them (49.1%) of women could identify two correct responses of the signs of pneumonia out of the possible three. Even 13.3% of the women could identify all the three signs of pneumonia. While almost all the participants (91.3%) heard about HIV/AIDS but only one out of every five (20.7%) knew that measles can be prevented by vaccination (Table 3).

Regression analysis showed that women with higher level of education achieved substantially higher scores (p<0.0001). Although it was seen that higher the number of family members in the household there was a reduction in the knowledge score but it was not statistically significant (p=0.15). Higher knowledge scores were seen in Hindu religion but that was not statistically significant (p=0.70). However, it was seen that with increase in age of the women the knowledge score increased by 0.04 (p=0.002). The multiple regression analysis also revealed that age had a statistically significant effect on the knowledge (p=0.01). Education level also was statistically significant in multiple regression analysis and with age the knowledge score increased by 0.02 (p=0.03).

Pregnancy and delivery

Ninety-five (95%) of the women had received antenatal check-ups during their antenatal period. It was interesting to note that 54.3% of women had received three or less antenatal check-ups including 5.1% had zero antenatal check-ups in their antenatal period. Most of these check-ups were conducted in sub-centres/PHCs. Almost 3/4th of the women had their delivery conducted in a government healthcare facility but with such a robust maternal and child health program of the government, there were 13 (4.2%) deliveries that were conducted at home. However, it was good to note that these deliveries were conducted by trained birth attendants. A total of 222 (74%) deliveries were attended by ANMs in mostly the PHCs. Even if the deliveries were primarily conducted in the health institution, it was noted that only 45.2% of the newborns were put on mother’s breast after delivery immediately or within one hour (Table 4).

Vaccine coverage

The vaccine coverage was well documented in the mother and child protection card for all the children and it was kept safely in their respective sub-centres/ other nearest government health facility in the ‘mother and child protection card tracking bag’. Thus, all the women had their card and the verification process was done properly. Even if, the institutional delivery was 95.8%, it was noted that only 87.3% of the newborns received the birth dose of Hep-B. It was noted that 73.3% of those newborns received Pentavalent-3 vaccine accordingly. There was a fall in vaccination coverage of the children as their age increased. The reason for the same could not be elicited. In addition, it was seen that only 65.7% of the children were fully immunized and AEFI reporting was also very low, reported in only 16 children (5.3%) (Table 4).

Treatment seeking behaviour

A total of 162 (54.1%) of the women said that they would seek help from their ASHAs/ANMs either directly by visiting the health facility or by visiting their home or over telephone whenever their child is ill, and only 20% of the women went to a doctor to seek the first treatment for their children. Almost half of the women (49.9%) reported to get their medicines usually from the nearest government health facility as it is free of cost and 35.8% said that they prefer to collect it from pharmacy/chemist shop as according to them the quality of medicines in private set-up are good. More than 2/3rd (72.6%) of the women said that they did not keep any medicines at home and they would collect it from ASHAs/ANMs whenever needed. While 41.4% of the women said that their home always had paracetamol tablets. It was interesting to note that only 10% of the women said that they kept ORS at home pointing that the women had poor awareness on diarrhoea. It is also must be noted that 16 women (5.2%) did not know what medicines they have kept in their house as they could not identify its purpose (Table 5).

*More than one options could be selected

DISCUSSION

This study documented that majority of the study population had poor knowledge on diarrhoea and measles prevention and management, some of the inappropriate birth practices, insanitary latrine facilities, and low vaccination coverage in older age groups. This study showed that the health knowledge scores increased with access to higher education, and the results were at par with other studies.^16,17 This study found that the coverage of three doses of pentavalent vaccine was only in 73.3% while NFHS-5 data for Assam documents that it has increased to 82%. This difference is may be because the study area had poor healthcare coverage routinely due to its remote location and terrain.

This study has many limitations. The findings of this study on the level of health knowledge and treatment seeking and preventive behaviours are representative of the area selected for the study rather than whole of Assam. Secondly, the study may have a bias as the data collection was done during rainy season and sufficient time could not be given by the women and the responses were elicited by the field investigators in a quick time interval. Despite the limitations, this study had strong implications for future research. This study covered a wide range of issues together. However, the majority of the studies were conducted on mothers or women of reproductive age-group on a single issue like prevention and management of diarrhoea, malaria, pneumonia, knowledge and practice of antenatal care, child birth and breast feeding many studies have also been conducted to document the knowledge on malaria on parents, caregivers or in the community.^18-29 Of all the above mentioned studies, mostly they were conducted in either the facility level or in urban settings, this research study captures the voice of the women from a rural background and on multiple issues in a single paper that too in their natural environment in the community is a useful contribution in this field. Further, as this study uses regression analysis to assess various factors on the overall health knowledge of the women has created new possibilities of measuring health knowledge over time. This study helped in the development of appropriate, area-specific health information programme to address the key gaps in the knowledge and practice on various issues of health.

CONCLUSION

This study found low levels of health knowledge on diarrhoea and measles - prevention and its management, poor practice of antenatal care among women and poor vaccination coverage among the older children. The women had poor knowledge on insecticide treated mosquito bed-nets and poor water, sanitation, and hygiene practices in the community. There was also poor treatment seeking behaviour among the women. Higher education and older age of the women were strong determinants in the overall health knowledge score.

ACKNOWLEDGEMENTS

Authors would like to acknowledge the support provided by the ASHAs/ANMs working in those villages. Secondly, the authors acknowledge the efforts of the field investigators from the Department of Community and Family Medicine, AIIMS Guwahati for meticulous collection of data.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet. 2003;361(9376):2226-34.
2. 2. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS; Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet. 2003;362(9377):65-71.
3. 3. Bryce J, el Arifeen S, Pariyo G, Lanata C, Gwatkin D, Habicht JP; Multi-Country Evaluation of IMCI Study Group. Reducing child mortality: can public health deliver? Lancet. 2003;362(9378):159-64.
4. 4. Victora CG, Wagstaff A, Schellenberg JA, Gwatkin D, Claeson M, Habicht JP. Applying an equity lens to child health and mortality: more of the same is not enough. Lancet. 2003;362(9379):233-41.
5. 5. Claeson M, Gillespie D, Mshinda H, Troedsson H, Victora CG; Bellagio Study Group on Child Survival. Knowledge into action for child survival. Lancet. 2003;362(9380):323-7.
6. 6. Office of the Registrar General, India. Special bulletin on maternal mortality in India 2018-20: SRS maternal mortality bulletin. New Delhi: Office of the Registrar General, India, Ministry of Home Affairs; 2022.
7. 7. United Nations Children’s Fund. Child survival and the SDGs: Looking ahead: Child survival and the Sustainable Development Goals. 2021. Available at: https://data.unicef.org/topic/child-survival/child-survival-sdgs/. Accessed on 16 May 2026.
8. 8. UNICEF/WHO. Meeting on Child Survival Survey-based Indicators, New-York. 2004. Available at: https://www.unicef.org/montenegro/media/7971/file/MNE-media-MNEpublication316.pdf. Accessed on 16 May 2026.
9. 9. Bhutta ZA, Darmstadt GL, Hasan BS, Haws RA. Community-based interventions for improving perinatal and neonatal health outcomes in developing countries: a review of the evidence. Pediatrics. 2005;115(2):519-617.
10. 10. Rosato M, Laverack G, Grabman LH, Tripathy P, Nair N, Mwansambo C, et al. Community participation: lessons for maternal, newborn, and child health. Lancet. 2008;372(9642):962-71.
11. 11. Bang AT, Bang RA, Baitule SB, Reddy MH, Deshmukh MD. Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. Lancet. 1999;354(9194):1955-61.
12. 12. Manandhar DS, Osrin D, Shrestha BP, Mesko N, Morrison J, Tumbahangphe KM, et al. Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet. 2004;364(9438):970-9.
13. 13. India Village Directory. Guwahati North, Kamrup, Assam: India Village Directory; 2011: 7-9.
14. 14. North Guwahati (Pt). Kamrup, Assam. Statistical handbook Assam 2019. Guwahati: Directorate of Economics and Statistics, Government of Assam; 2020: 31.
15. 15. Villages list of North Guwahati (Pt) sub-district, Kamrup, Assam. Available from: https://www.viewvillage.in/villages-of-tehsil/north-guwahati-pt-2126. Accessed on 29 May 2026.
16. 16. Glewwe P. Why does mother’s schooling raise child health in developing countries: evidence from Morocco. J Hum Resour. 1999;34(1):124-59.
17. 17. Andrzejewski CS, Reed HE, White MJ. Does where you live influence what you know? Community effects on health knowledge in Ghana. Health Place. 2009;15(1):228-38.
18. 18. Rasania SK, Pathi S, Matta S, Singh D. Knowledge and attitude of mothers about oral rehydration solution in few urban slums of Delhi. Health Populat Perspect Issue. 2005;28(2):100-7.
19. 19. Taha AZ. Assessment of mother's knowledge and practice in use of oral rehydration solution for diarrhea in rural Bangladesh. Saudi Med J. 2002;23(8):904-8.
20. 20. Rakhshani F, Ansari Moghadam AR, Alemi R, Moradi A. Knowledge, perceptions and prevention of malaria among women in Sistan va Baluchestan, Islamic Republic of Iran. East Mediterr Health J. 2003;9(3):248-56.
21. 21. Seck I, Fall IS, Faye A, Ba O, Tal-Dia A. Malaria knowledge, attitudes and practices among women living in the rural area of Poponguine, Senegal. Med Trop (Mars). 2008;68(6):629-33.
22. 22. Gálvez CA, Modeste N, Lee JW, Betancourt H, Wilkins RL. Peruvian mothers' knowledge and recognition of pneumonia in children under 5 years of age. Rev Panam Salud Publica. 2002;11(2):99-108.
23. 23. Uwaezuoke SN, Emodi IJ, Ibe BC. Maternal perception of pneumonia in children: a health facility survey in Enugu, eastern Nigeria Ann Trop Paediatr. 2002;22(3):281-5.
24. 24. Bashour H, Abdulsalam A. Syrian women's preferences for birth attendant and birth place. Birth. 2005;32(1):20-6.
25. 25. Chandrashekhar TS, Joshi HS, Binu V, Shankar PR, Rana MS, Ramachandran U. Breast-feeding initiation and determinants of exclusive breast-feeding - a questionnaire survey in an urban population of western Nepal. Public Health Nutr. 2007;10(2):192-7.
26. 26. Chatman LM, Salihu HM, Roofe ME, Wheatle P, Henry D, Jolly PE. Influence of knowledge and attitudes on exclusive breastfeeding practice among rural Jamaican mothers. Birth. 2004;31(4):265-71.
27. 27. Mayhew M, Hansen PM, Peters DH, Edward A, Singh LP, Dwivedi V, et al. Determinants of skilled birth attendant utilization in Afghanistan: a cross-sectional study. Am J Public Health. 2008;98(10):1849-56.
28. 28. Hlongwana KW, Mabaso ML, Kunene S, Govender D, Maharaj R. Community knowledge, attitudes and practices (KAP) on malaria in Swaziland: a country earmarked for malaria elimination. Malar J. 2009;8:29.
29. 29. Oguonu T, Okafor HU, Obu HA. Caregivers's knowledge, attitude and practice on childhood malaria and treatment in urban and rural communities in Enugu, south-east Nigeria. Public Health. 2005;119(5):409-14.