Elsevier

Social Science & Medicine

Volume 86, June 2013, Pages 66-78
Social Science & Medicine

Review
Understanding 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

https://doi.org/10.1016/j.socscimed.2013.02.031Get rights and content

Abstract

Diarrhoea, pneumonia and malaria are the largest contributors to childhood mortality in sub-Saharan Africa. While supply side efforts to deliver effective and affordable interventions are being scaled up, ensuring timely and appropriate use by caregivers remains a challenge. This systematic review synthesises qualitative evidence on the factors that underpin household recognition and response to child diarrhoea, pneumonia and malaria in sub-Saharan Africa.

For this review, we searched six electronic databases, hand searched 12 journals from 1980 to 2010 using key search terms, and solicited expert review. We identified 5104 possible studies and included 112. Study quality was appraised using the Critical Appraisal Skills Program (CASP) tool. We followed a meta-ethnographic approach to synthesise findings according to three main themes: how households understand these illnesses, how social relationships affect recognition and response, and how households act to prevent and treat these illnesses. We synthesise these findings into a conceptual model for understanding household pathways to care and decision making.

Factors that influence household careseeking include: cultural beliefs and illness perceptions; perceived illness severity and efficacy of treatment; rural location, gender, household income and cost of treatment. Several studies also emphasise the importance of experimentation, previous experience with health services and habit in shaping household choices.

Moving beyond well-known barriers to careseeking and linear models of pathways to care, the review suggests that treatment decision making is a dynamic process characterised by uncertainty and debate, experimentation with multiple and simultaneous treatments, and shifting interpretations of the illness and treatment options, with household decision making hinging on social negotiations with a broad variety of actors and influenced by control over financial resources. The review concludes with research recommendations for tackling remaining gaps in knowledge.

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,

References (139)

  • A.A. Ellis et al.

    Home management of childhood diarrhoea in southern Mali – implications for the introduction of zinc treatment

    Social Science & Medicine

    (2007)
  • N. Friend-du Preez et al.

    Stuips, spuits and prophet ropes: the treatment of abantu childhood illnesses in urban South Africa

    Social Science & Medicine

    (2009)
  • H. Hildenwall et al.

    Local illness concepts – implications for management of childhood pneumonia in eastern Uganda

    Acta Tropica

    (2007)
  • O.A. Idowu et al.

    Perceptions and home management practices of malaria in some rural communities in Abeokuta, Nigeria

    Travel Medicine and Infectious Disease

    (2008)
  • B.F. Iyun et al.

    Acute respiratory infections – mothers' perceptions of etiology and treatment in south-western Nigeria

    Social Science & Medicine

    (1996)
  • G. Jones et al.

    How many child deaths can we prevent this year?

    Lancet

    (2003)
  • K. Kallander et al.

    Can community health workers and caretakers recognise pneumonia in children? Experiences from western Uganda

    Transactions of the Royal Society of Tropical Medicine and Hygiene

    (2006)
  • V.R. Kamat

    “I thought it was only ordinary fever”! cultural knowledge and the micropolitics of therapy seeking for childhood febrile illness in Tanzania

    Social Science & Medicine

    (2006)
  • M.A. Leach et al.

    New therapeutic landscapes in Africa: parental categories and practices in seeking infant health in the Republic of Guinea

    Social Science & Medicine

    (2008)
  • L. Leonard

    Where there is no state: household strategies for the management of illness in Chad

    Social Science & Medicine

    (2005)
  • L.B. Lerer et al.

    ‘A bothersome death’ – narrative accounts of infant mortality in Cape Town, South Africa

    Social Science & Medicine

    (1995)
  • C. Marston et al.

    Factors that shape young people's sexual behaviour: a systematic review

    Lancet

    (2006)
  • J. Mutai et al.

    Socio-cultural practices of deciduous canine tooth bud removal among Maasai children

    International Journal of Dentistry

    (2010)
  • H.A. Mwenesi

    Social science research in malaria prevention, management and control in the last two decades: an overview

    Acta Tropica

    (2005)
  • G.O. Adjei et al.

    Parents' perceptions, attitudes and acceptability of treatment of childhood malaria with artemisinin combination therapies in Ghana

    Ghana Medical Journal

    (2009)
  • P.B. Adongo et al.

    How local community knowledge about malaria affects insecticide-treated net use in northern Ghana

    Tropical Medicine & International Health

    (2005)
  • I.S. Ahmed et al.

    Knowledge, attitudes and practices of mothers regarding diarrhoea among children in a Sudanese rural community

    East African Medical Journal

    (1994)
  • C.K. Ahorlu et al.

    Community concepts of malaria-related illness with and without convulsions in southern Ghana

    Malaria Journal

    (2005)
  • C.K. Ahorlu et al.

    Socio-cultural determinants of treatment delay for childhood malaria in southern Ghana

    Tropical Medicine & International Health

    (2006)
  • C.K. Ahorlu et al.

    Children, pregnant women and the culture of malaria in two rural communities of Ghana

    Anthropology and Medicine

    (2007)
  • I.O. Ajayi et al.

    A qualitative study of the feasibility and community perception on the effectiveness of artemether-lumefantrine use in the context of home management of malaria in south-west Nigeria

    BMC Health Services Research

    (2008)
  • G.O. Akpede et al.

    Severity signs of childhood diarrhoea in north eastern Nigeria

    Journal of the Royal Society of Health

    (1995)
  • S. Almroth et al.

    Grandma ahead of her time: traditional ways of diarrhoea management in Lesotho

    Journal of Diarrhoeal Diseases Research

    (1998)
  • G.K. Amofah et al.

    Intended response of caretakers of pre-school children to acute respiratory infection in a rural district in Ghana

    East African Medical Journal

    (1995)
  • G.K. Amofah et al.

    Perceptions of caretakers of pre-school children on acute respiratory infection (ARI) in a rural district in Ghana

    West African Journal of Medicine

    (1998)
  • M. Amuyunzu

    Willing the spirits to reveal themselves: rural Kenyan mothers' responsibility to restore their children's health

    Medical Anthropology Quarterly

    (1998)
  • M. Amuyunzu-Nyamongo et al.

    Health seeking behaviour of mothers of under-five-year old children in the slum communities of Nairobi, Kenya

    Anthropology and Medicine

    (2006)
  • O.S. Arulogun et al.

    Management practices of childhood malaria among caregivers in Ojo Military Cantonment, Lagos, Nigeria: implication for child survival

    African Journal of Medicine & Medical Sciences

    (2009)
  • O.A. Babaniyi et al.

    Management of diarrhoea at the household level: a population-based survey in Suleja, Nigeria

    East African Medical Journal

    (1994)
  • E. Barnett-Page et al.

    Methods for the synthesis of qualitative research: a critical review

    BMC Medical Research Methodology

    (2009)
  • C. Beiersmann et al.

    Malaria in rural Burkina Faso: local illness concepts, patterns of traditional treatment and influence on health-seeking behaviour

    Malaria Journal

    (2007)
  • M.E. Bentley

    Household behaviors in the management of diarrhea and their relevance for persistent diarrhea

    Acta Paediatrica

    (1992)
  • G.L. Birbeck

    Traditional African medicines complicate the management of febrile seizures

    European Neurology

    (1999)
  • J. Bryce et al.

    Programmatic pathways to child survival: results of a multi-country evaluation of Integrated Management of Childhood Illness

    Health Policy Plan

    (2005)
  • H. Bukirwa et al.

    Pharmacovigilance of antimalarial treatment in Uganda: community perceptions and suggestions for reporting adverse events

    Tropical Medicine & International Health

    (2008)
  • H.A. el Bushra et al.

    Perceived causes and traditional treatment of diarrhoea by mothers in Eastern Sudan

    Annals of Tropical Paediatrics

    (1988)
  • A.I. Chibwana et al.

    Socio-cultural predictors of health-seeking behaviour for febrile under-five children in Mwanza-Neno district, Malawi

    Malaria Journal

    (2009)
  • M. Chopra et al.

    Effect of an IMCI intervention on quality of care across four districts in Cape Town, South Africa

    Archives of Disease in Childhood

    (2005)
  • J. Chuma et al.

    Treatment-seeking behaviour, cost burdens and coping strategies among rural and urban households in Coastal Kenya: an equity analysis

    Tropical Medicine & International Health

    (2007)
  • Critical Appraisal Skills Programme (CASP)

    Ten questions to help you make sense of qualitative research

    (2002)
  • Cited by (126)

    • Perception of mothers about Acute Respiratory Infections (ARIs) and risk factors affecting children Under 5 Years (U5Ys) in Fiji

      2022, Journal of Pediatric Nursing
      Citation Excerpt :

      Acute ear infections can lead to ear drum damage and chronic otitis media if not properly treated especially in developing countries and this can cause deafness and therefore learning disabilities (Assane et al., 2018; Bosch et al., 2016; Jolliffe, 2016). The ARIs among children are globally linked to smoking (Jones et al., 2015; Miyahara et al., 2017), indoor pollution (Dherani et al., 2008; Fakunle et al., 2016); cooking with biofuels and other fuels (Fakunle et al., 2014; Patel et al., 2019); overcrowding in homes (Ujunwa & Ezeonu, 2014); lower socioeconomic status (Rumchev et al., 2017; Rehman & Ishaq, 2018); cultural factors (Colvin et al., 2013; Bedford & Sharkey, 2014), demographic factors (Dherani et al., 2008; Jones et al., 2015); poor education level of mothers (Tazinya et al., 2018; Kazi & Azad, 2009); inadequate breastfeeding (Arifeen et al., 2001; Chantry et al., 2006); contact with other people who have ARIs (Broor et al., 2001; Raykarmakar & Paul, 2017); lack of knowledge of risk factors (Alluqmani et al., 2017; Gálvez et al., 2002); and poor perception of the mothers (Kauchali et al., 2004; Rashid et al., 2001). Fiji, as a Pacific Island Country (PIC) experiences a high prevalence of ARIs among children.

    View all citing articles on Scopus
    View full text