We interviewed a total of 12 mothers (six who sought care and six who did not); 12 fathers (six who sought care and six who did not); three primary health center in-charges and three PPMVs; and held two focus group discussions with eight to ten community leaders in each LGA (see Figure 2). Due to time constraints, the final sample of public and private service providers was reduced from the originally proposed six to three and the focus group discussions among community leaders were reduced from three to two per LGA. We present findings based on the four modes identified in the Colvin et al. framework that influence care-seeking behavior in response to child diarrhea, pneumonia, and malaria.
Caregiver’s recognition and response to the illness
According to all respondents, mothers were the primary caregivers for children, responsible for daily feeding and caring for the child. Interviewers asked parents to describe the symptoms their child had during their most recent illness. Responses from parents were largely consistent across LGAs and care-seeking patterns. In cases where children had diarrhea, parents described loose and frequent stools. For children with a fever, parents described the hotness of their body. Parents who suspected their child had symptoms of pneumonia described symptoms that included coughing, difficulty breathing, and shortness of breath. While these were the primary disease-specific symptoms, parents also described several symptoms that were common across illnesses including, fatigue, weakness, and an inability to eat well or play.
“I know how that child plays and whenever the child is not able to move around in such manner, I will know that there is a problem somewhere. Aaah when I first returned from the farm that evening, the child was sleeping and I woke the child up in order to feed the child because I know the child would have been hungry by that time, because I stayed long in the farm that very day. (coughing) the child woke up and ate just a little. (mother, Izzi)
Many symptoms overlapped across illnesses. For example, children with diarrhea or a cough also had fever. Parents described difficulty breathing, convulsions, extreme weakness, excessively crying, not sleeping, and loss of consciousness as symptoms that indicated the illness was severe. Parents were more likely to seek immediate care if the illness was perceived to be severe. However, all parents reported providing some form of care, regardless of severity, and whether it was first initiated inside the home or not (i.e., traditional, self-treatment, or at a chemist or biomedical provider). Most parents recognized the connection between poor sanitation and hygienic practices and diarrhea. They also mentioned that poor nutrition and teething could contribute to diarrheal illnesses. Many parents recognized the connection between mosquitos and malaria or fever, but sometimes considered the symptom of fever and the medical diagnosis of malaria as the same. A number of parents believed that spending too much time in the sun could cause fever. Nearly all parents and a number of primary health center in-charges interviewed believed pneumonia was caused by being cold or not dressed warmly. Some mothers in Idah LGA attributed pneumonia-like symptoms to certain foods, such as groundnuts.
“It should be the groundnut that I the mother eat and she takes through the breast milk. The elder sister also gave her groundnut to eat, and it causes cough.” (mother, Idah)
Seeking advice and negotiating access to care with the family
Mothers are in close contact with the child and as a result are able to recognize when the child is not feeling well. When the child is ill, mothers typically initiate a conversation about the child with the father. These conversations frequently occur in the evening, when both parents are at home, and can result in a delay in seeking care if the illness began earlier in the day. The discussions center on the child’s symptoms and severity, the type of treatment that is needed, whether money or transport is required for care seeking and the quality of the provider. Mothers who have access to a cell phone may choose to reach out to the fathers earlier in the day. In general, mothers and fathers reported finding agreement in their care-seeking decisions. The discussions typically remain within the nuclear family, between the mother and father unless the case is particularly serious and requires resources beyond their means.
“I had a discussion with my wife that night, when the coughing started, like I said we could not go out because it was late, so she suggested we wait till morning before we could take the child out to seek care in the hospital in Okene. Before the morning she came to me again that we would have to leave early in the morning because the cough had not stopped and it looked like it was getting worse.” (father, Okehi)
Strong gender norms relating to childcare and decision-making emerged during the interviews. Across all four LGAs, respondents agreed that the role of the father is to financially support the child and provide money for treatment.
“The mother takes care of the sick child; the father’s own is to bring the money” (mother, Okehi)
The mother is responsible for providing physical care for the child and taking the child for treatment. Fathers will take the child for treatment if the mother is not available or will occasionally accompany the mother to the biomedical provider, particularly if the illness is perceived to be severe or if he has access to a means of transportation. Because the father is usually responsible for paying for the care, he ultimately makes the decision about when and where the child receives care. A number of respondents acknowledged that a mother would delay care seeking if money was not available from the father and that the child’s illness could become increasingly severe as a result. Deviations from this norm were only apparent when the mother has financial autonomy. In this case, both mothers and fathers agreed that a woman could contribute resources for care and in some situations take decisions without permission from the husband.
“What other duty do we have if not to make sure that the children are healthy. The man will make sure that money for the treatment is provided but if a woman has she would bring too. It’s not like it must be the man” (mother Ohaozara).
In addition to financial support, respondents from Kogi and to a lesser extent in Ebonyi indicated that cultural norms dictate that the child belongs to the father and the mother does not have the right to seek care without permission from the father. If the mother takes the child without permission from the husband, he could refuse to pay the bill or send her back to her father for disobeying him, or hold her responsible for the child’s illness or death. The belief that a child belongs to a father independent of a woman’s financial autonomy was more common in Kogi state, perhaps due to the higher percentage of Muslim communities.
“she needs permission from me or my father. This is because if anything goes wrong she will be blamed for not telling anybody.” (father, Ohaozara)
In some situations when the father is away, family members such as a brother of the father may be assigned to help the wife if there is a problem. The relative may provide financial support or advice, particularly if they have more experience with children.
Most parents acknowledged that aside from limited prevention efforts promoted at the community level, the community members did not play a significant role in advising on or supporting care seeking and that these decisions primarily occurred in the home. Some caregivers did note that community members provided prayers and advice, checked in on the family, collected herbs to support treatment, and provided financial or logistical support if the family did not have the resources to obtain care. In Idah LGA in Kogi state, a number of respondents spoke about the social cohesion within the community. Some mothers in Idah LGA said that community leaders could provide permission for the mother to seek care outside the home if the father was not available. All respondents noted that community members did not prevent parents from seeking care for their child.
Making use of community based treatment options (i.e. the “middle layer” between home and clinic)
Parents often initiated some form of care through traditional healers, using medicines available at home or accessing treatment from chemists. A number of parents mentioned that traditional remedies are an effective means of treating a sick child, and this is based on experiences passed down through families.
“How I know about the drugs is that we do follow our father and go inside the bush and our father will get leaves and administer on a sick person and the person will be well” (father, Ohaozara)
Mothers and fathers learn from their parents which herbs are appropriate for different illnesses. Some mothers noted that certain herbs can help clean the stomach from the illness or that other traditional remedies such as palm kernel oil can help release the heat from the body during a fever episode. A mother may apply these remedies at night to soothe a child before they seek care in the morning. Traditional remedies are often seen as a more cost-efficient form of treatment since they are available freely in the bush. The only disadvantage seen in using herbs is that they can be time consuming to prepare.
Respondents from Idah LGA in Kogi spoke of traditional healers who diagnose and advise on how to treat children. Idah community leaders mentioned that the traditional herbs used to treat the children are passed down through the community elders and are similar in efficacy to those found in the hospital, and that the hospitals have access to more herbal medicines than those found in the community.
However, communities in Ohoazara LGA in Ebonyi believe that times have changed and parents rely less on traditional approaches.
“Their duty is when the parents notice that a child is sick, you ask for their advice from elderly people. In those days, they use kola, chicken blood, etc., to do some ritual and then tell you that the fever has been cured and it actually does. It is the grandfather and grand grandmothers that guide us then. Now it is no longer like that.” (male community leader, Ohaozara)
At times, particularly if the mother did not perceive the illness as severe, she would try to treat the child at home based on her knowledge from previous experiences with a biomedical provider or with medications leftover from a previous illness or purchased from a local chemist. For example, a number of mothers mentioned that they kept paracetamol at home and administered it to the child if they had a fever or applied balms and gave the child a hot bath to alleviate congestion. However, if the medications did not improve the condition, the mothers would seek another form of care.
In Nigeria, chemists or PPMVs are frequently the first source of care for under-five child illnesses. In addition to selling drugs, PPMVs can be a source of advice about illness and drug therapy in place of more formal care at health facilities even though most PPMVs have not received formal training in prescribing pharmaceuticals (21). Parents perceive chemists to provide good-quality care, but that they may not be equipped to handle serious illnesses. Some parents will frequent a chemist after receiving a prescription from a biomedical provider, while others will seek advice directly from the chemist on the type of medication to purchase. The families’ proximity to the chemist compared to the distance to a health facility also influences their choice, particularly if they are perceived to have drugs available of good quality and at a good price.
“They only way we don’t provide quality care is maybe they are not with enough money, so we do compromise. We give them on credit and they later come to pay. Unless if the person doesn’t want to buy on credit, we give them alternatives, or the person would just leave because he cannot afford the bill.” (male, PPMV, Idah)
Some families have a relationship with the chemist. The mother can take the child to the chemist when the father is away and the chemist can provide services on credit with the agreement that the family will make the payment in a few weeks.
“It is the one that I can afford. I used to go to the hospital but my husband was not around to give me money to give them. The chemist use to give me medicine, and when my husband comes back, he pays for it.” (mother, Ohaozara)
Accessing formal biomedical services
Decisions on when and where to seek care were multidimensional and did not always follow a linear path. Care seeking moved between providers, with some parents seeking care at chemists and then continuing to health facilities or starting with a health facility and then accessing prescriptions from a chemist. While some respondents have maintained their trust in traditional medicines, others noted Christian religion encourages Western medicine. Depending on factors such as illness severity, financial resources, and illness duration, some families will try traditional remedies first, and if the illness continues or becomes more severe, they then seek care with a chemist or biomedical provider at the health center or hospital. The sex of the child does not influence decisions on whether or not to seek care or where care is sought, according to all respondents asked.
“We have been used to herbal medicine and occasionally we subscribe to orthodox medications. The other day, my child took ill; after several herbal medications without improvement we went to the clinic and somehow, he was greatly relieved. However, we will be glad if we can have the orthodox medication cheaply, we will prefer it.” (mother, Idah)
Referrals occurred when a mother takes the child to a chemist, but the chemist is unable to offer the appropriate treatment.
Parents were hesitant to acknowledge cost and distance as a barrier to care seeking and emphasized the importance of the child’s life, whereas providers and community leaders perceived these issues as significant barriers for families.. However, some families in Idah LGA in Kogi state acknowledged that poverty meant they did not have money to seek formal treatment and they were forced to resort to herbal remedies to treat child illnesses.
“Money can actually delay the mother from seeking care; as a mother when you don’t have money, you would have to wait for the father. Money is a great factor. Imagine you get a prescription from the nurse, on getting to the chemist without money, nothing can be done.” (male community leader, Idah)
Parents and public and private health care providers acknowledged that families could access treatment on credit. Both PPMVs and biomedical providers said they would not refuse to provide care to a sick child if the family did not have money and they would search for the means to treat the child.
Community leaders perceived biomedical providers to be inaccessible to the poor because even though services are provided free of charge, transportation to the facility, obtaining laboratory tests and treatment are considered expensive. However, when an illness is severe or the child is not improving, mothers will seek treatment at a health facility.
“I considered it to be severe when the child did not respond to the drugs I have. I now knew that the case was beyond chemist, I then took her to the hospital. The child was coughing, and the body was hot.” (mother, Ohaozara)
Parents perceive a number of advantages when visiting the health facility. First, providers are more likely to administer a diagnostic test, which is considered a higher level of care because the provider is confirming the illness through a test and not simply providing care based on symptoms. Parents also expect short waiting times and strong interpersonal skills from providers across all levels of formal care. While parents consider these examples of good quality care, the ultimate measure of quality is that the child recovers.