title: Caregivers' Experiences of Pathways to Care for Seriously Ill Children in Cape Town, South Africa: A Qualitative Investigation.
abstract: OBJECTIVE
  Understanding caregivers' experiences of care can identify barriers to timely and good quality care, and support the improvement of services. We aimed to explore caregivers' experiences and perceptions of pathways to care, from first access through various levels of health service, for seriously ill and injured children in Cape Town, South Africa, in order to identify areas for improvement.
  
  
  METHODS
  Semi-structured, qualitative interviews were conducted with primary caregivers of children who were admitted to paediatric intensive care or died in the health system prior to intensive care admission. Interviews explored caregivers' experiences from when their child first became ill, through each level of health care to paediatric intensive care or death. A maximum variation sample of transcripts was purposively sampled from a larger cohort study based on demographic characteristics, child diagnosis, and outcome at 30 days; and analysed using the method of constant comparison.
  
  
  RESULTS
  Of the 282 caregivers who were interviewed in the larger cohort study, 45 interviews were included in this qualitative analysis. Some caregivers employed 'tactics' to gain quicker access to care, including bypassing lower levels of care, and negotiating or demanding to see a healthcare professional ahead of other patients. It was sometimes unclear how to access emergency care within facilities; and non-medical personnel informally judged illness severity and helped or hindered quicker access. Caregivers commonly misconceived ambulances to be slow to arrive, and were concerned when ambulance transfers were seemingly not prioritised by illness severity. Communication was often good, but some caregivers experienced language difficulties and/or criticism.
  
  
  CONCLUSIONS
  Interventions to improve child health care could be based on: reorganising the reception of seriously ill children and making the emergency route within healthcare facilities clear; promoting caregivers' use of ambulances and prioritising transfers according to illness severity; addressing language barriers, and emphasising the importance of effective communication to healthcare providers.
authors.affiliation: Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom.
authors.forename: Caroline H D
authors.initials: CH
authors.lastname: Jones
authors.affiliation: Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom.
authors.forename: Alison
authors.initials: A
authors.lastname: Ward
authors.affiliation: Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Peter W
authors.initials: PW
authors.lastname: Hodkinson
authors.affiliation: Primary Health Care Directorate, University of Cape Town, Cape Town, South Africa.
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Reid
authors.affiliation: Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Lee A
authors.initials: LA
authors.lastname: Wallis
authors.affiliation: Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom.
authors.forename: Sian
authors.initials: S
authors.lastname: Harrison
authors.affiliation: Department of Paediatrics, University of Cape Town, Cape Town, South Africa.
authors.forename: Andrew C
authors.initials: AC
authors.lastname: Argent
mesh_terms: D000293:Adolescent; D017028:Caregivers; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003422:Critical Care; D016638:Critical Illness; D003695:Delivery of Health Care; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D013019:South Africa; D062606:Tertiary Care Centers