The central aim of this study is to investigate the association between socio-economic status and selection of treatment for childhood diarrhoea among care givers in sub-Saharan Africa using multilevel multinomial regression analysis. The result shows that, caregiver's choice of treatment for childhood diarrhoea depends on several individual and neighbourhood measures of socio-economic status. Specifically, at the individual level, the analysis indicate that choice of medical centre for managing childhood diarrhoea was highly associated with the caregiver's and her partner's educational attainments. Highly educated caregivers had a higher odd of utilizing medical centre for managing childhood diarrhoea; this finding is in contrast to a study conducted in another developing region of the world with high prevalence of childhood diarrhoea . Whereas, our findings are compatible with those of many others [31–33], that have documented positive association between maternal education and choice of medical centre for managing childhood diarrhoea. The finding that partners education is associated with choice of medical centre is in consonance with what had been reported earlier [33, 34].This finding, further confirms the protective role of fathers education, as an additional reinforcement factor for mothers decision to seek appropriate care when managing childhood illness. The positive association between parental education and choice of medical centre as noted in this study further reverberates its importance for child survival in developing world .
In sub-Saharan Africa, fathers are the overall head of the household and sometimes decides where care is sought . Hence, it is not surprising as noted in this study that, caregiver's partner's education, is associated with patronage of pharmacy store and medicine vendors and to some extent home care for managing diarrhoea episode. In addition, the decision of the educated caregivers to use home treatment, have been attributed to their ability to utilize health information wisely.
The influence of wealth status on caregiver's propensity to choose private and public medical centres when managing childhood illness has been documented in the literatures [30, 39–41]. This is however, not noticed in this study. Although this study shows that, care givers from poorer households compared with those from poorest household engaged in home care as an alternative option for managing childhood diarrhoea. This finding is not surprising, it had been reported elsewhere that households sometimes do engaged in self medication especially when the cost of treatment in medical centre is high [42, 43]. On the other hand this study joined other studies in documenting care givers' occupation, as another important factor influencing choice of treatment [33, 39, 41]. In this study, being a manual worker is closely associated with selection of medical centre, while being a professional working class is associated with patronage of pharmacy store or medicine vendors.
Geographic location, place of residence in particular, has been shown to be another form of disparity[44, 45], which could prevent access to utilization of care. This study shows that, residing in rural area, though statistically not significant, is associated with likelihood of patronizing traditional healers. Of the main interest in this study, is to examine the effect of neighbourhood socio-economic disadvantaged after controlling for individual SEP on clustering of selected treatment options around the neighbourhoods. The multilevel multinomial regression models indicate that, with all other factors being held constant, living in highly socio-economically disadvantaged neighbourhood is associated with less likelihood of using medical centre, pharmacy or vendors. The results of the between caregivers variation in the choice of treatment at the community-level indicates that several other factors which might be in part due to the caregivers neighbourhoods play a greater role in the individual choices. This finding suggests that, compositional characteristics of the caregivers are less important than that of the community with regards to individual choices.
Study limitations and strengths
This study is without limitations and should be mentioned. First, the findings from this study are based on data from cross-sectional survey and the initiation of the caregivers to the health system for managing childhood diarrhoea. It is however, possible for care to be sought from more than one provider upon the failure of the initial treatment. Second, we used an indirect measure of household wealth status. However, as DHS surveys do not collect data on income, the use of household possession has been shown to be relevant in developing country settings. Finally, the analysis was based on self reported diarrhoea morbidity has reported by the care giver which could be subject to recall bias. In spite of these limitations, the strength of our study lies in the unique characteristics of the DHS. The DHS are nationally representative, and allows for findings to be generalized across the entire country. In addition, the design and the variables included in the survey are the same across countries, and thus, making it possible for us to be able to pool the data from these countries.