Danger in disguise
Spotting the warning signs of severe childhood illnesses

Many children die in developing countries without ever reaching a health facility. What stops caregivers from accessing medical services? Why are they accessed late? Are caregivers 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.

Where quality of care is adequate the decision to seek medical care can be crucial for child survival, especially 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.

The researchers surveyed 264 caregivers and conducted 60 in-depth interviews in Kintampo district, Ghana. They explored barriers to care-seeking and 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. Reasons include that some conditions are seen to be ‘not-for-hospital’, effectively treatable at home or by a healer, or because caregivers lack money for transport, hospital bills or medication. But when caregivers think that children have a fatal illness, they often manage to overcome financial barriers by borrowing money or selling assets, although this may result in delays to accessing services. 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. Efforts to improve care-seeking tend to focus on teaching caregivers to recognise symptoms. 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 should trigger action.

Researchers recommend developing guidelines that lay out the symptoms caregivers should ideally recognise. It may be better to focus on a small number of general danger signs, such as refusal to breastfeed or extreme lethargy, and on symptoms that caregivers recognise but do not see as abnormal or dangerous. Teaching numerous illness-specific symptoms or symptoms that caregivers do not know exist or that are not recognised when they occur may not be effective. Health workers developing educational strategies should explore and build on local health beliefs and how caregivers themselves recognise severe illness.

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

zelee.hill@lshtm.ac.uk

See also:

‘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 et al, 2003

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