ReviewUnderstanding careseeking for child illness in sub-Saharan Africa: A systematic review and conceptual framework based on qualitative research of household recognition and response to child diarrhoea, pneumonia and malaria
Highlights
► Decision making is characterised by uncertainty, experimentation, and shifting interpretations of illness and treatment. ► The person who controls household finances usually gets to decide on the course of treatment. ► Who that person is often shifts during an illness as family and community networks are mobilised. ► Drug sellers, community health workers, herbalists and traditional healers were a critical ‘middle layer’ of providers. ► ‘Waiting’ is an important, conscious element of the process of household recognition and response.
Introduction
Diarrhoea, pneumonia and malaria constitute the largest disease-specific contributors to childhood mortality in sub-Saharan Africa (Friberg et al., 2010; Kinney et al., 2010). This burden could be significantly reduced with ready access to well-established effective and affordable prevention and treatment interventions (Jones, Steketee, Black, Bhutta, & Morris, 2003). A number of facility and community-based initiatives to improve access to and uptake of these interventions have been implemented across sub-Saharan Africa, with varying success (Arifeen et al., 2009; Bryce, Victora, Habicht, Black, & Scherpbier, 2005; Chopra, Patel, Cloete, Sanders, & Peterson, 2005; Hopkins, Talisuna, Whitty, & Staedke, 2007; Sazawal & Black, 2003). The main challenge is delivering these interventions equitably at scale within existing health systems and encouraging appropriate use by caregivers and families at community level (Schellenberg et al., 2003). As a result, childhood malaria, diarrhoea, and pneumonia burdens in sub-Saharan Africa remain stubbornly high.
While current policy efforts focus on scaling up the supply of community treatment for child illness, the effectiveness of these efforts hinge on the myriad decisions that families face about how and whether to respond to childhood illness as well as their complex and often constrained choices about how and where to access care. These decisions are determined largely by social, cultural and religious norms, beliefs about disease aetiology, acceptability of interventions, and local decision-making practices. Understanding these complex and inter-related influences on the demand side of treatment is critical to ensuring available interventions are relevant, acceptable and equitable and that they become common practice among caregivers and households (Bentley et al., 1988; Gove & Pelto, 1994; Pelto & Pelto, 1997).
There is a sizeable body of published qualitative research that explores household recognition and response to child diarrhoea, pneumonia and malaria in sub-Saharan Africa. Like other systematic reviews of qualitative evidence on health issues like TB treatment adherence (Munro et al., 2007), help-seeking behaviour in cancer patients (Smith, Pope, & Botha, 2005), unsafe medical injection practices (Reeler, 2000), and young people's sexual behaviour (Marston & King, 2006), this systematic review assesses the quality of the available evidence and synthesises the findings of these studies. While several recent reviews focus on malaria (Maslove et al., 2009; Mwenesi, 2005; Williams & Jones, 2004), a few reviews on diarrhoea exist from the 1980s (Bentley, 1992; Bentley et al., 1988; Weiss, 1988) and a few reflections on applied anthropology findings on acute respiratory infections date from the 1990s (Pelto & Pelto, 1997), none respond to the current efforts to address childhood illnesses in an integrated manner and none are ‘systematic’ in their approach.
While there is increasing attention being paid to delays in careseeking due to lack of awareness or health systems failures (Kallander et al., 2011), models of careseeking for child survival have remained static for the last 30 years (Mosley & Chen, 1984). While the identification and organisation of determinants of child survival into one framework has stood the test of time, it suggests a linear pathway of careseeking that is out of step with the multiple negotiations households make with various actors and health care options in constrained and unregulated plural health systems today (Bloom & Standing, 2008; Sharkey, Chopra, Jackson, Winch, & Minkovitz, 2012; Williams & Jones, 2004).
Our synthesis considers these three childhood illnesses together on the assumption that many of the findings will pertain to all three; where possible, we highlight any findings that appear disease specific. The objectives of this review are to: critically examine lessons learned from published social science research, develop a conceptual framework outlining how households in sub-Saharan Africa recognise and respond to child diarrhoea, pneumonia, and malaria, and identify gaps to inform future research.
Section snippets
Methods
Systematic reviews of qualitative research aim to identify, appraise, and summarise the current state of knowledge on a specific focused topic using systematic and transparent processes. In this review we use a comprehensive search strategy to identify relevant literature, predefined inclusion and exclusion criteria, quality assessment of included studies, and a recognised method for synthesising the findings across included studies. The goal in all systematic reviews is to minimise bias in the
Description of included studies
We identified a total of 5104 unique articles, of which 112 studies met the inclusion criteria (Fig. 1). Table 2 summarises their characteristics and a full list of included studies and their characteristics can be found in the Supplementary Data. Many of the included studies are cited in the findings below but those not cited are listed here (Adjei et al., 2009; Ahmed et al., 1994; Ahorlu et al., 2007; Almroth et al., 1998; Amofah et al., 1995, 1998; Amuyunzu-Nyamongo and Nyamongo, 2006;
Summary of findings
These studies point to a range of individual and contextual factors that influence household recognition and response including: cultural beliefs and illness perceptions; perceived severity of the illness and the perceived efficacy of treatment options; rural location, gender, household income and cost of treatment options. Prevention strategies were less reported in contrast to treatment strategies, which included a balance of traditional and biomedical types of medicine, as well as a variety
Role of the funding source
Co-authors (AG and JK) representing the funding source (UNICEF) helped interpret the review findings and implications, advised on writing up the findings, and contributed to revising drafts of the manuscript. All authors had full access to all of the data in the study and the corresponding author had final responsibility for the decision to submit for publication.
Authors' contributions
AG, JA, HS and CC designed the review methodology. AG and JA undertook study identification and selection. CC, HS, AS, JdH, NO, and TM extracted data, assessed study quality, and analysed data. CC wrote the first draft. All authors participated in the interpretation of results and writing of the final manuscript.
Conflicts of interest
None declared.
Acknowledgements
We are grateful to Theresa Diaz, Nancy Binkin, Osman Mansoor, Paula Claycomb, Mickey Chopra at UNICEF NY for their input at critical stages of the review. Thanks also to the external experts involved in either defining the review terms of reference or finalising studies selected for review: Peter Winch, Birger Forsberg, Stefan Peterson, Rachel Tolhurst, John Rohde, Monica Sharma, Bobbie Person, Mimi Nichter, Vinay Kamat, Margaret Bentley, Olivier Fontaine, Jane Kengeya-Kayondo, Franco Pagnoni,
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