Many children die in developing countries without ever reaching a health facility. What stops caregivers from accessing medical services? Are they able to spot the symptoms and signs of severe illnesses? Research by the London School of Hygiene and Tropical Medicine tackles this question in rural Ghana.

The decision to seek medical care is crucial for child survival in areas with limited access to health services. To make the right choice, caregivers must:

• recognise when a child is ill
• know when an illness needs treatment outside the home
• seek timely and appropriate medical care.

But many child deaths in developing countries are due to delays in accessing care. The researchers interviewed 264 caregivers in eight villages in Kintampo, Ghana, to discover barriers to care-seeking. They found that general signs of illness and symptoms relating to convulsions, measles and bloody diarrhoea are well recognised. But there are three problems relating to recognition of other symptoms:

• Caregivers do not know that some symptoms exist. Examples include those related to dehydration or acute lower respiratory infections.
• They know that some symptoms, such as those signalling malnutrition, are danger signs but do not spot them when they occur.
• Although they recognise other symptoms, including frequent stools, fever, cough, difficult or fast breathing and restlessness, caregivers rarely see these as abnormal or dangerous.

Poor recognition of danger signs is not the only barrier to care-seeking. Caregivers do not seek medical care in half of the episodes they recognise as severe. Some conditions are seen to be ‘not-for-hospital’ (one third) or treatable at home or by a healer (30 percent). Another third do not seek care because they lack money for transport, hospital bills or medication. But when caregivers think that children have a fatal illness, they overcome financial barriers by borrowing money or selling assets. Physical access is less of a barrier: care-seeking is not higher in villages with a health facility than those without.

So, care-seeking is a complex process, strongly influenced by health beliefs. Interventions to improve care-seeking tend to focus on teaching caregivers to recognise symptoms, increasing access to health facilities, or screening for sick children in the community. The researchers argue that strategies must move away from a narrow symptom recognition focus because:

• There are other significant barriers to seeking care.
• Symptom recognition is not always necessary for care-seeking.
• Not all recognition problems can be addressed.
• Little is known about which symptoms or symptom combinations trigger action.

The researchers recommend developing guidelines that lay out the symptoms caregivers should ideally recognise. The ‘Integrated Management of Childhood Illness’ list of 30 danger signs is too complex to include in an educational approach. So it may be better to focus on a small number of general danger signs, such as refusal to breastfeed or extreme lethargy, rather than on numerous illness-specific signs. Healthworkers developing educational strategies should explore and build on how caregivers themselves recognise severe illness and avoid teaching symptoms that have no meaning to the local people.

Source(s):
‘Recognizing childhood illnesses and their traditional explanations: exploring options for care-seeking interventions in the context of the IMCI strategy in rural Ghana’, Tropical Medicine and International Health 8 (7): 668-676, by Z. Hill, C. Kendall, P. Arthur, B. Kirkwood and E. Adjei, 2003
HINARI subscribers can access the full-text article here. Full document.

Funded by: World Health Organisation

id21 Research Highlight: 25 September 2003

Further Information:
Zelee Hill
Department of Epidemiology and Population Health
London School of Hygiene and Tropical Medicine
49-51 Bedford Square
London
WC1B 3DP
UK

Contact the contributor: zelee.hill@lshtm.ac.uk

London School of Hygiene and Tropical Medicine, UK

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