title: 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.
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.
authors.affiliation: Centre for Infectious Disease Epidemiology and Research, Falmouth 5.49, School of Public Health and Family Medicine, University of Cape Town, Observatory 7925, Cape Town, South Africa. cj.colvin@uct.ac.za
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Colvin
authors.forename: Helen J
authors.initials: HJ
authors.lastname: Smith
authors.forename: Alison
authors.initials: A
authors.lastname: Swartz
authors.forename: Jill W
authors.initials: JW
authors.lastname: Ahs
authors.forename: Jodie
authors.initials: J
authors.lastname: de Heer
authors.forename: Newton
authors.initials: N
authors.lastname: Opiyo
authors.forename: Julia C
authors.initials: JC
authors.lastname: Kim
authors.forename: Toni
authors.initials: T
authors.lastname: Marraccini
authors.forename: Asha
authors.initials: A
authors.lastname: George
mesh_terms: D017954:Africa South of the Sahara; D002648:Child; D003967:Diarrhea / Q000175:diagnosis*; D005191:Family Characteristics; D006801:Humans; D008288:Malaria / Q000175:diagnosis*; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011014:Pneumonia / Q000175:diagnosis*; D036301:Qualitative Research