Determinants and experiences of care-seeking for childhood pneumonia in a rural Indian setting: A mixed-methods study

IntroductionPneumonia is a leading cause of under-five mortality, with 30 million annual cases in India. Despite national guidelines, significant barriers to timely and appropriate care-seeking persist. Caregivers often face financial constraints, lack of awareness, mistrust in government facilities, and a preference for non-registered medical practitioners (non-RMP), delaying effective treatment. This study explores care-seeking behaviors, associated sociodemographic factors, and barriers to access to appropriate healthcare for childhood pneumonia in rural India. MethodsThis study is part of a broader implementation research (IR) initiative and represents its formative phase. This mixed-methods study was conducted in Palwal district, Haryana, covering 42 villages (population: 107,440). A cross-sectional survey identified suspected pneumonia cases among 9,593 under-five children through house-to-house visits using a structured checklist. Data on sociodemographic characteristics, health insurance, care-seeking patterns, and provider preferences were collected. Directed Acyclic Graphs (DAGs) identified potential confounders in the association between care-seeking behaviour and key exposure variables. Additionally, qualitative in-depth interviews explored caregivers perceptions, decision-making, and healthcare barriers to pneumonia management. Quantitative data were analysed using logistic regression, while qualitative data were thematically analyzed using the Three Delays Model. Suspected under-five pneumonia cases caregivers and families were actively engaged in this formative phase to inform Phase II implementation strategies of broader IR, ensuring community-driven and contextually relevant strategies. ResultsAmong 231 suspected pneumonia cases, 97% of caregivers sought medical care, but 71% consulted non-RMPs, and only 3.6% visited government facilities. Seeking appropriate care was associated with higher maternal education (AOR 6.5, 95% CI: 2.7, 9.7) and higher wealth index (AOR 1.7, 95% CI: 1.0, 2.6). Thematic analysis revealed delays due to symptom misinterpretation, reliance on home remedies, financial constraints, gender biases, mistrust in public healthcare services, and logistical barriers. ConclusionDespite high care-seeking rates, provider preferences, socio-cultural factors, and systemic barriers delay appropriate pneumonia treatment. Addressing these challenges requires improving awareness, enhancing public healthcare trust, and strengthening frontline health worker engagement. This study underscores the role of structured beneficiary involvement in refining pneumonia management strategies to ensure sustainable, community-driven interventions.