Health care-seeking behavior for childhood illnesses in western Kenya: Qualitative findings from the Child Health and Mortality Prevention Surveillance (CHAMPS) Study

Background

Globally, under-five mortality rates (U5MR) have declined; however sub-Saharan Africa on average has 74 deaths per 1,000 live births, compared to the global rate of 38 deaths per 1,000 live births in 2020¹. In Kenya, U5MR has reduced from 101 to 41 per 1000 live births since 1990², but achieving the 2030 Sustainable Development Goal of 25 deaths per 1,000 live^3,4, will require a deeper understanding of how decision-making is made by the family before formal healthcare is sought. A large proportion of children still die due to delays in seeking appropriate care attributed by caregivers choosing to first use over-the-counter (OTC) medication and/or traditional medicine^5–7.

Health seeking behavior is defined as a complex process guided by a decision-making process that is governed by socio-cultural, structural and economic factors^7–11. Belief systems ingrained by cultural beliefs define causes of illness under two broad categories: Those caused by supernatural etiology and those caused by biological pathogens. The category determined to cause an illness provides the basis for health-care seeking decision making^12,13. Studies conducted in Tanzania, report that the determination of a natural or supernatural cause of illness is made by the caregiver’s perception of severity and etiology^14,15. Previous studies indicate that lack of knowledge and delay in recognition of the severity of an illness are reasons for delayed health care seeking^16,17. Lack of awareness of severity informs health care decisions that are not favorable to the child’s health such as use of OTC medications and engagement of traditional healers rather than formal health care^17–19.

Community based information is needed regarding drivers to health care decision making. Understanding what governs caregivers’ health seeking decisions for childhood illnesses is essential to understanding the health seeking behavior. This is important in formulating policies and strategies that optimize response to illness. Using the constructs of the Partners for Applied Social Sciences (PASS) model, we explored how cultural, social and economic factors drove health care decision making.

Methods

Results

A total of 88 participants were interviewed in 29 IDIs, 5 FGDs and 11 SSIs, of whom fifty-one (58%) were female. Thirty-eight (43%) had at least secondary education or higher, and most 80/88 (91%) were Christian (Table 1).

Thematic findings

We identified four main themes: illness interpretation (theme 1), social relationships and illness response (theme 2), medical pluralism (theme 3) and healthcare access (theme 4). Table 2 summarizes the thematic areas as well as the major findings for each area.

Discussion

This study revealed that caregivers’ interpretation of childhood illness is reflected in the treatment-seeking behavior for child illness in western Kenyan communities. Illnesses were believed to have two broad etiologies, supernatural and biological. Interpretation is made based on signs and symptoms of a particular illness and presumed cause of illness²³. Often illnesses with supernatural etiology such as those that follow breaching a taboo or caused by witchcraft are first treated using traditional medicine, a finding which is congruent with previous studies^24–26. Measles was one such disease, with severe consequences to be expected if biomedicine was chosen instead. Similarly, in Tanzania, degedege, a folk illness with symptoms of malaria, was given mystical etiology and treatment with traditional medicine prioritized to avoid death^23,27. Beliefs about the cause of the illness results in customs and practices that can adversely affect illness outcome²⁸. Our findings report that malaria was recognized as a biologically-caused illness, and this shows caregivers’ awareness of malaria symptoms. These findings are similar to other studies which report that malaria symptoms were easily recognized and treated at the hospital^29,30.

The respondents report a communal approach to finding treatment for childhood illness where a caregiver with a sick child would be advised on appropriate care for the child. PASS framework posit that health-seeking behavior is founded on social values whereby a particular behavior is expected¹². Seeking and receiving advice was socially expected from caregivers of young children in this context. Therefore, social relationship is important in illness recognition and response and is derived from social values. Consultation with neighbors, mother in law and spouse is common in our setting, similar to other studies findings^6,17. In urban areas, where caregivers lived far from their extended family, neighbors stepped in to provide caregivers with care-seeking advice. This was noted to contribute to delays in seeking healthcare^6,26,30. Some studies have established the importance of fathers’ financial support and participation in childhood illness^31–33, however, our findings show that fathers were not involved in a child’s treatment because mothers concealed doctor’s advice about child’s treatment. Concealing doctors' advice may hinder father’s involvement or participation in decision making and this may deny a child clinical management that they need to restore health. Therefore, there is a need to understand why mothers are not involving fathers in health seeking for children.

Consistent with previous reports, medical pluralism was common among caregivers^34,35. The treatment course varies with some starting treatment at the health facility then switching to a traditional medicine when the illness gets worse. These decisions are often consultative as is socially expected which can pressurize caregivers to oblige to advice on appropriate treatment. Price’s study conducted in South Africa among caregivers seeking care during a fatal childhood illness report that traditional medicine was used as a last resort when caregivers were feeling desperate or when the illness gets worse³⁶. Hooft, et al. also reported that most caregivers sequentially seek multiple healthcare providers and treatment modalities until there is a perceived benefit¹⁷. Our findings reveal gaps in communication between the medical practitioner and caregiver, as the medical practitioner fails to inform caregiver of treatment and progress with the caregiver, the caregiver isn’t aware of what to expect. This shows a need for counseling for caregivers with critically ill children who may get desperate when they don’t notice immediate improvement. Our findings also reveal that treatment with traditional medicine first caused delays in definitive care leading to severe illness and death. Previous research has also documented the importance of prompt clinical management to avert severe morbidity³⁴. These findings show a nonlinear health care seeking pathway as described by the PASS model where health care seeking behavior is made and reevaluated depending on the patient’s response to treatment^10,15.

The 2030 Sustainable Development Goals emphasize having all people receive quality care without financial hardship³. Community members find healthcare unaffordable in private facilities during public health worker’s strikes. During these periods, caregivers consult local pharmacies which they perceive to be affordable, a finding consistent with a study conducted in Kilifi county in Eastern Kenya³⁷. Referral to higher levels of care is an important component of child survival, but caregivers report not being able to afford to take their children to referral facilities. This leads them to seek alternative treatment which are perceived to be more affordable and still effective. This shows a gap in the implementation of the integrated management of childhood illness (IMCI) strategy which aims at strengthening referral pathways to improve health outcomes³⁸. The decision not to take a child to the referred facility is still not clearly understood given the fact that Free Health Care Initiative (FHCI) and Universal Health care was instituted to protect vulnerable populations from catastrophic expenditures and to promote equity in health care provision³⁷. The full cost to a family of a very sick child’s care needs to be better understood in order to improve healthcare access in our setting, particularly as other studies in the region have also reported that poverty can be a major deterrent to ‘appropriate’ health care seeking behavior.

This study has four main limitations. First, we asked caregivers about hypothetical situations, and did not describe the caregivers’ actual behavior and rationale for actions. Second, we did not explore perceptions about health services, which can influence health seeking behavior. Finally, it is possible that participants expressed what they perceived to be appropriate or socially desirable responses.

Conclusion

Health-seeking decisions are driven by both intrinsic and extrinsic factors, and understanding community drivers to health-seeking behavior is important in formulating policies and interventions that improve health outcomes. Our findings indicate that a strong health education program at community level could improve caregivers’ ability to interpret signs and symptoms of common childhood diseases, understand danger signs that require immediate clinical intervention, and involve fathers in decision-making around healthcare for their children. We recommend involving caregivers in the development of educational program interventions ensures that the messages are tailored to the audience’s needs. This collaboration helps create more effective and relevant health promotion strategies.